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ED 307 395 CE 052 006 






Report to Congress on the Study of the Role of Allied 
Health Personnel in Health Care Delivery. 
Health Resources and Services Administration 
(DHHS/PHS), Rockville, MD. Bureau of Health 
Jun 88 

365p.j Subsequently published in further edited form 
by the National Academy Press, 2101 Constitution 
Ave., NW, Washington, DC 20418, under the title: 
"Allied Health Services: Avoiding Crises. Report of a 
Study* (ISBN-0-309-03896-0, PB: $29.95; HB: 
$39.95) . 

National Technical Information Service (NTIS) , 5285 
Port Royal Road, Springfield, VA 22161. 
Reports - Research/Technical (143) 

EDRS PRICE MF01/PC15 Plus Postage. 

DESCRIPTORS Accreditation (Institutions); "Allied Health 

Occupations; »Allied Health Occupations Education; 
Demand Occupations^^ "Employment Projections; Females; 
•Futures (of Society); Labor Market; *Labor Needs; 
Minority Groups; Nontraditional Students; 
Postsecondary Education; *student Recruitment 


This report, the result of an 18-month study by the 
NAS Institute of Medicine, Committee to Study the Role of Allied 
Health Personnel (including two workshops with invited experts), 
examines the diverse set of health care occupations that fall under 
the umbrella term "allied health." The report is organized in eight 
chapters. Chapter 1 introduces the concept of allied nealth 
occupations and traces briefly the evolution of 10 fields. Chapter 2 
examines various data sources and discusses ways of forecasting the 
demand for and 'supply of allied health personnel. Chapter 3 looks at 
forces such as demography, disease patterns, the structure of the 
health care delivery system, and women's study choices that have an 
impact on the demand and supply of allied health personnel. Chapter 4 
reviews national projections of the demand for allied health workers 
up to the year 2000. In Chapter 5, recommendations are offered to 
increase recruitment of students, including minority students, into 
allied health education progreuns and to improve the capacity of 
educational institutions to deliver allied health programs. 
Presenting the employer's perspective^ Chapter 6 reviews options for 
correcting and adapting to supply imbalances and outlines a role for 
health care administrators in enhancing the size and effectiveness of 
the allied health work force. Chapter 7 discusses state licensure and 
other types of control of allied health personnel. Chapter 8 examines 
long-term care and the needs it poses for allie(^ health personnel. 
Each chapter contains references. Appendices include the 
Congressional mandate, list of workshop participants, list of allied 
health job titles and progreun classifications data on labor 
supply/demand estimates and projections, criteria for approval of 
certifying agencies, and a list of historical source material. 

Report to 

X^ongress on the Study of the 
^ole of Allied Health Personnel 
in Health Care Delivery 

Allied Health Services: Avoiding Crises 
Report of a Study 

Division of Health Care Services 
Institute of Medicine 
National Academy of Sciences 

JUNE 1988 


Ot1,c. of EduCl.on.l Bes..rc^ .no 

oriQinating it«h...t> 

rep'oduclion quality 

ITTZ^^^ or op'r^'ons Stated .r> this docu 
• Foir^tSOt vie* O' ,„r,tmK%r\\ Official 

OERi ^os'tlor^ or po'icy 

U S DEPARTMENT OP HEALTH A HUMAN SERVICES Public T.-hh Scr\ • heii'h Re^ouries «nd ServicfS Admumtrition 

^0' 2 



^'HRSA-'Helping Build A Healthier Nation** 

The Health Resources and Services Adrr.inistra- 
tion has leadership responsibility in the U S Pub- 
lic Health Service for health service and resource 
issues HRSA pursues its objectives by 

• Supporting states and communities in deliver- 
ing health care to underserved residents, moth- 
ers and children and other groups, 

• Participating in the campaign against AIDS, 

• Serving as a focal point for federal organ trans- 
plant activities, 

• Providing leadership in improving health profes- 
sions training; 

• Tracking the supply of health professionals and 
monitoring their competence through operation 
of a nationv/ide data bank on malpractice claims 
and sanctions; and 

• Monitoring developments affecting health facil- 
ities, especially those in rural areas. 

This report Is available through the U.S. Department of Commerce, 
Natiof tal Technical Information Service (NTIS), 5285 Port Royal 
Road, Springfield, VA 22161 

Bie Ooonittee wauld lUoe to gratfc..^ly acJoxwledge the contributions 
of nary people and organizations v*» provided assistance and infonnaticn 
to this study. Chief among the organizations are the allied health 
professional associations thenselves. Despite apprehensions ftcn time to 
time about what oonclusions and reocmnendations the Oamd fcee night 
produce, these organizations generously rose to the challenge of providing 
tiie inf omation the Ooninittee requested. Bie Ocnndttee solicited ir^jut 
fron a wixle-ranging set of allied health associatias and wishes to thank 
each of them. Special acknowledgonents, however, are in orcter for those 
associations representing the ten fields studied in depth, as well as the 
American Society of Allied Health Professions and the National Society of 
Allied Health Professions. The Coranittee was also aided by Dr Gercy 
Kandnski, Dsan of Cincinnati Technical college, v*x> provided us with 
infonnation trm the organization of two-year college allied health deans 
an allied health pr ogr an i B in ocmunity colleges. 

Several goverment agencies provided critical assistance in the use of 
federal data systems. Oir deepest thanks go to Ann Kahl and her staff, 
SanJy Gamliel, Steven Use, and William Austin, «ho sper± considerable 
tiaiB with the staff discussing the Bureau of Labor statistics (BIS) 
■Bthodology and their work on specific allied health fields. Alan Eck, 
also of the EES, generously offered his ej^sertise in the areas of supply 
areJ ocn^iational nobility. Deborah Jerold of the Department of Education 
was extremely helpful in providing the Ocnndttee with higher education 
projections. Numerous Individuals in the central office and facilities of 
the Veterans Administration veve willing to describe their eaqierienoes in 
recruiting, retaining and educating allied health staff. Above all, we 
wish to thank our ^nnsors, the Bureau of Health Professions, Health 
Rescuroes and Services Administration. Hdlio Albertini, the study 
project officer, and other staff nenbers were eager to meet the 
Ccnndttetj-'s needs for guidcurse and infonnation throuc^Kut the study. 

We also wish to acknowledge a nurtber of institutions who welccned 
Oonndttee nenbers and staff, allowing us to tour their facilities and 
^>eak to allied health personnel in the workplace. Ihese institutions 
include the Sisters of Hercy Health Corporation, Harvard Comunity Health 
Plan, Bancix) Los Amigo Medical Center, Beverly Manor Convalescent 
Hospital, Oi Lok Senior Health Services, Garden Sullivan Hospital, VA 
Medical Center Palo Altc, Durham County General Hospital, Beverly Health 
Care Center, I^xboro, N.C. , and the Berry Hill Nursing Heme. 

Oir thanks also goes to J. Warren Perry, Alexander McMahon, and John 
DiBiaggio for attending Conndttee workshops and providing advice to 
Oonndttee and staff. 

Finally, ve wish to thank all those v*» participated in our public 
hearings and workshops. These individuals are listed in Appendix li. 




NimAM RICHARDGGN, Hi.D., CSiaiman*, EbCBcutive Vioe President and Provost 
Pennsylvzoiia State Uhiversity, University HuSc, EA. 

JOHN E. MTEWT, M.D.*, Medical Adsdsor, Beverly Qitexprises, Pasevkna, 

STANLEY BNM, M.D.*, nx>fessor aid Oiaiznan, Department of Radiology, 
Hoq)ital of the Uhviersity of Pennsylvania, Riiladelphia, pa. 

nrxSNCE S. CPOWELL, M.A.*, consultant in Program Develcpnent, and 
Editor, Oocupatlonal Hhisrap^ in Health care, Pasadena, CA. 

E. HPRVEY ESTES, M.D.*, Director, Family Medicine Divisicjn, Defaartment of 
OoDBunity t Family Medicine, Duke university Medical School, 
Durham, NC 

GARY L. FIIfSMAN, Hi.D., President, Association of university Prograns, 
in Health Administration, Arlington, VA. 

POIliSf Fm, M.A. , Professor, School of Allied Health Professions, 
university of Connecticut, storrs, CI. 

ALGEANIA FREEMAN, Ri.D. , Dean, School of Public and Allied Health, East 
Tennessee State university, Johnson City, Tennessee. 

SlfTTER ARUNE MCX3CWAN, Vice President for Operations, Providence Ho^ital, 
Cincinnati, CH. 

ROBEKT E. EARniA, Ph.D., President, Mantgcniery CCnnunity College, 
Rockville, MD. 

EDmiE H. SCXSENRIOi, M.D., Director, Continuing Studies, Johi» Hopkins 
School of Public Health, Bedtimore, MD. 

C. ECMARD SCHHARTZ, Executive Director and Vice President for Medical 
Center Hoqpital of the university of Pennsylvania, Philadelphia, PA. 

FRANK SIDAN, Ri.D.*, Chaiznan, Department of Eooncnics, Director, Health 
Policy Center, Vanderbilt Institute for Public Policy Studies, 
Vanderfoilt university, Nashville, IN. 

«Menber, Institute of Medicine 

EKUL M. STARIES, Assistant Superintendent, Kaaniltcn Ocunty Departaent 
of Educaticn; Menber, Tennessee House of Rqnr^^sentatives, 
Ghatanooga, TM. 

REFD SIKENGHMI, D.D.S., Ri.D., Dean, School of Allied Haalth, W^Der 
State CSollege, Ogden, Utah. 

tfiRA srxSER, Ri.D., Professor of Eooranics, School of Bducaticn, 
Stanford Uhiversi^, Stanford, GA. 

FHEBA EE TGRNYAY, R.N., Ri.D.*, Ptofessor, School of NUrsing, Diix±or, 
FHJ Clijiical NUrse Scholars I^nogram, Uhiversity of Mashingtcn, 
Seattle, NA. 

NftNCY wans, Ph.D., Professor of B^sical Oherapy, M3I Institute of Health 
Ptofessicns, Massachusetts General Hsopital, Boston, MA. 

KWRL D. YGHDV, Director, Division of Health Care Senrices 

MICHAEL L. MniMAN, Study Director 

aJNNY G. YODEK, Associate Director 

JESSICA TQWNSQID, Research Associate 

MARZANNE P. KEEMAN, Research Associate 

CAR OL C . MCKET^Y, Research Associate 


HAUACE K. HAIEKFAUi, Editor, Institute of Medicine 

BUIH wa9i 



iAbl£ of cxKmns 



OAFEER 1. fAiat is Allied Health? 

CHAFHK 2. j^]proaches to Denand and Sifply 

CHAFIER 3. Faroes and Trends in Desooand and Supply 

GHAFTER 4. Derand and SappLy far Ten Allied Health Fields 

CHAPIER 5. Ihe Itole of Education Policy in Infliiencing Simply 

CHAPTER 6. Die Heetlth Ciare BDaplcyer's PQr^)ective 

CHAFFER 7. Lioensuie and Other Mochanians for Regulating 
Allied Hasdth PsrsGnnel 

CHAFIER 8. Allied Health Perscnne}. and Long-Term Care 


I. Oongressicnal Mandate 

II. Meeting and Workshop Participants 

m. A Sanple of Allied Health Job Titles and 

A Classification of Instructional Programs in Allied Health 

IV. Estimates of the Current Si^ly in Ten Allied Health Fields 

V. Projections of Denand and Si^ly in Occqpaticais 

VI. Minnesota Sunrise Provisions 

VII. National OGnmission for Hc^alth Certified Agencies' Criteria 
for tf^gaxr/al of Certifying Agencies 

VIII. List of Historicsd Source Material 


Ihis report is the result of an 18-nonth study by a oomittee of 
the institute of Hadicine to sxplore policy isaies suxroundina the xoles 
of allied health peracmel. 

nnoBiited by a oongressiaial vandate oontained in Fiiblic Law 99-129, 
the Health Axxfestions Tndning Act of 1985 (Appendix I) , aitl iaplesented 
through a oontract with the Health Besouxoes and Services Administxaticn 
of the Depar ient of Health and Haoan Sendees, the study npresents the 
first major jdepen dent examination of the dlvcone set of health caxe 
occupations that often fall under the uriarella tern "allied health". 

Study BacStQTound 

AltlKug^h scne allied health fields such as dietetics date bade to 
the 19th century, it %as the federal health professicns legislation of the 
1960s that gave life to the conoept of a collectivity now known as allied 
health pezsonnel. 

Despite the withdrawal of nost direct federal siqpport for allied 
health education in the early 1980s allied health leaders convinced 
Oongress that such a large part of the health care woricforoe (ran?ing in 
estiinates from one to almost four millicn people) should not continue to 
go unnonitorad and unstudied, eepecdally «hen so much about the health 
care systen is undergoing swaqping change/^lhere is increasing pnssuiB 
txva both piiblic and private sectors to aal^il costs; there is 
introduction of nsw sophisticated health iSftbnologies; there are growing 
nunbers of elderly; there is increasing attention to individuals %dth 
chrad-c disabilities; and there are drastic dsvelopnents in disease, such 
as the acquired iaoune deficiency ayndrone (AIDS) epidemic. 

How the headth care systan adqpts to these pressureo dcpenSs in 
large part on whether tmrtaers with the reg^oisite education are available 
at the rig^ place and time. Ihus, careful nnricinnTiriTt of future personnel 
needs has never been more isportant than now. However, making sound 
policy decisions about education, regulation and other matters that affect 
siqpply and danand for allied health personnel is difficult. This is in 
part because they have been among the least studied eloents of the health 
care aysten Jr. r eepo n s e to this deficiency, in 19f * Congress lardated 
this national study. 



mterpratatlcn of the OongressiGnal Qiazge 

Qongress posed five tasks fbr this study, nhese inquiries \mre not 
raised in ttiB specific ccntext of mdstijng or propos e d federal 
legislation, but rather a joroader concern that a large body of health care 
vorkers has received insufficient attention relative to their iipcrtanoe 
in future health care. In effect, Qongress asked for infomation about 


1. Assess the role of allied health personnel in health care delivery. 

2. Identify projec t ed needs, availability, and reqiuirenents of various 
l^pes of health care delivery systons for each ^pe of allied 
health personnel. 

3. Investigate current practices under which each '^pe of allied 
health personnel obtain licenses, czedentials, wd acczBditation. 

4. Assess changes in ptocRams and curricula for the education of 
allied health personnel and in the delivery of services by such 
personnel which ai3 necessary to meet the needs and requirements 
identified pursuant to paragra^i (2) . 

5. Assess the role of the Federal, State and local gcvernnents, 
educational institutions, and health care facilities in ineeting the 
needs and reguireoents identified pursuant to paragrBfah (2) . 

this mjor o o mx a n en t of the health warkfarca in order to determine whether 
corrective action is needed, and if 30, where r^ponsibility for such 
action rests. 

Ihe study oomnittee was directed to aasoflo the role of allied 
health personnel in the delivery of healtl^t care. Ihe ccnndttee has 
interpreted this charge as a request for better knowledge about the ways 
in which allied health practitioners are deployed, their Amotions, their 
relationships with other health care practitLmers, and the settings in 
which they %K3rk. In viddition, the charge has been interpreted as a need 
for elxicidation of the various factors and fbroes—education and training, 
cqployer re(]LiireDents, third party payer policies, the regulatory 
BpparatJB, to name several isportant ones— that ^lape that role. 


Tbm Moom Itcn In the oongressional charge, in effect, asks the 
ocDBiittee to ptccvide its best jud^nent as to vhether the needed future 
services of allied health practitioners will be available. This raises 
qjastions about the tioy the allied health labor sarket operates and 
vhether aartet adjiutnents can be eaqpected to take place (for iistance, 
salary increases if dnand for persomel lAnild outpace siqpply) before 
service dislocation or quality erosion occurs. Although nudi of the 
report addresses the lilwly future oarket donand for allied health 
Markers, the ocnmittee has not uverlooload the fact that seme infjortant 
service needs say net be set now. Longr-tera uare pccvides a current 
maofle of the lack of good jobs and reidburseBsnt unteminij^ the 
nation's ability to supply some basic services. 

In the diarge's third iton, Congress raquests an examination of 
licensure and other farms of cxedentialling in allied health fields. The 
ocuBittee belie^/es this sxpresses a canoem about the imbalance between 
the costs and inefficiencies of regulation on one hand and the need to 
protect oonsuners tran poor quality care on the other. To sake the 
desired adjustaents a better understanding is needed of the current 
situation, the contribution of xagulation to quality, and the diverse 
costs of regulation. 

The fourth it'SD of the congressional chargu-^on examination of 
education yiujiaim and curricula— relates to conoem about whether thrry 
are keeping in step %dth the changing nature of health services. Ohe 
ooonittee also interpreted this segment of t)w charge to inclu3e a 
oonsideration of whether allied health education p rogi ai ifc i are likely to be 
able to conpete for higher education resources aiv3 for stidents interested 
in pursuing technically oriented careers. 

The final ouigressional request is for an assessment of the 
abilities of the major legislative, educational, and health care entities 
to make the adjustments that will ensure that allied health personnel can 
fulfill their poteitial in the future health care delivery system, if 
intervention is nee led. who has the final responsibility and leveragb to 
act, and how can th?y know when and how to intervene? 

Study Approach 

Ob address the questions posed by Oongress, the admittee and study 
staff solicited information fZtan a broad array of otganizatiora, including 
the allied health professional associations, state regulatory agencies and 
higher educa t i on coordinating bodies, and federal agencies such ts the 
Bureau of Health Rcofessions and the Bureau of labor Statistics. The 
oonnittae held two v w ika h cps with invited eoqperts and a public neetl^ on 
the regulation of allied health personnel. Ihe first of the two worl^hcps 
caioe u isd tfas future denand fbr allied health workers; the seoonl 


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oonoexned education and sqpply of wrfcers. (Appendix H prcrvides a list 
of parbic^^pants to each of these BBetings.) Ihe staff and cxxnoittee 
menbexs visited haalth care provider institutions, including seveial 
long-^terv caxe facilities, WDb, and a inulti*-hoGpital systen. 

Ihe ccnoittee has not oollecbed priMxy c^ta, tout has used existing 
data from a variety of sources to focus en isfxartant policy issues. Ohese 
poli^ issues ware explored prinarily thrcug|h an examination of ten allied 
health fields. Individually, these fields reprssent different facets of 
allied health occupations. Collectively tiiey reveal some OGmDcn threads 
in the way all allied health fields can rsGpond to the challenge of 
changing health care systens. 

This study is a tim^. #tep toward addressing a neglected topic in 
he ilth care policy. Ohe o xsittee did not have the benefit of large-s^e 
sample surveys nor an extensive toody of enpirioal literature. Recognizing 
that a rich data toase say not be in the imaadiate ftjture for allied 
health, ve suggest strategies for enhancing existing data to issprtr/B the 
grounds on %Aiicii decisioMakars act. 

Allied health is an ill-defined term. Because there is no 
oo na e nsu s about idhich occupations constitute al? ied health, and because 
the Bore ocqprehensive definitions encciqpass so many fields that stud/ is 
inpiMKi^icable, the oonnittee settled \Jpan a set of fields that exclvde 
some occipatlons that readers might expect, to find. Among those excluded 
are nurses, nurse practitioners, midlives, physician assistants, 
pharmacists, and social vorloers and mental health counselors. Guiding the 
conmittee's selection of study fields was the federal health professions 
legislation and the need to cast lic^t upon large but relatively unstudied 

Major Study Thanes 

Ihe folloving report is intended for a %dde audience: allied 
health professional organizations, administrators at educational 
institutions, state regulatory and licensing bodies, enployers of allied 
health personnel, and policynakers at both the i^te and federal levels. 
Although the study's findings are moe^ often based on national data and 
trends, thB analysis is intended for use by all actors looking to the 
future including those at the local level—the college adndnistrator 
considering itether to offer allied health programs, the legislature 
voting on a licensure law% the hone care agency setting salary levels for 
enploy^eB, and the therapist oonsidering whether to establish an 
independent practice. 

Ihe reader viU virti to be alert fbr several thenes that have 
glided the Ocm&ittee in determining areas fbr reconnendations to its 
audiences. Ihese thenes, derived from the stud/ activities and interwoven 
througlhaut the report, include: 

o allied health personnel as an under*reoognized bat important 
hman roocfurce 



- 5- 

the need for data and research to provide the basis for moiB 
•f factlv* UM of aUled health peraomel 

the iMed for health care and eduaation iistitiitias to asslr*-t 
9tat±i other in adjusting to nav realities in tl^e way services 
will be deliversd in tK future 

o the ftagility of acme ot the educaticn piooiam* that provide 
nev entrants into the f iel(ta 

o the i^xartanoe of oonijetitive levels of ccniiensaticn in a 
labor laxtet %«wre individuals with technical and service 
oriented aidlls %dll be at a pnodxan 

o balancing qual ity ujuue im with those of cost, flexibility, 
and oaplcyment ofiporbunity In the regulatory policy arena. 

Organization of the Report 

CSiapter 1 introduces the subject of this study, allied health 
cocx^wtions, and briefly traces the evolution of 10 fields. Ch^Jber 2 
•Kamines varicus data souroes and difiowsfts ways of forecasting the dbdnani 
for and «¥ply of aUied health perecmel. Chapter 3 locks at forces such 
as dMDography, disease patterns, the structure of the health care delivery 
system, and wonen's study choices that inpact on the denand and siEply of 
allied health personnel. Chapter 4 reviews national projection of the 
donand for allied health wockers iq;) to the year 2000 and presents the 
oamittee's assessment of future denand and sfplv based on its own 
assunptions and projections of suf^ily. 

In Chapter 5, the ocnmittoe addresses the contribution of 
educ at io n al cwtpit to fature simply. RBComaendatioK are offered to 
incmase tecruitiBBn t of students, including minoril^y students, into allied 
health education prograns and to iiqprove the cqpucity of educaticned 
institutions to support allied health ■arogr ans . Chs^jter o also <Hnnr?nn 
the levels and content of education nuaded to prepare practitioners for 
the fixture workforoe. 

In presenting the cnployer's penpective in Chapter 6, the 
ocranittee rsvims options for correcting and adapting to supply <i*»i«iTy^ 
and charts a role fbr health care adhninistrators in oiiancing the size and 
effectiveness of the allietS health warkfaroe. 

Chapter 7 d n scrihoc the various nechanians of control of allied 
health perKxnel, fbousing principaUy on the problois state legislators 
face in Baking decisions about lioensure and other fame of ocosational 
regulation. Ohj chapter wir h ns l zes the need for flexibility in the 
fijnctions of allied health personnel. 



- 6- 

Chapter 8 takes up Icng-'tenn care and the needs it poses for allied 
health personnel. 



Ttda npart xwults frcn the f ixBt large naticnal study of the 
anterprlM ImcMn as allied health. It identifies the najor funcrticra of 
allied health pnctitioners, tix> have been relatively unxecxignized by 
health pdic^Bedoers. Ihis situation often leaves the policymdoerB unawaxe 
of the iqpact of their decisions on allied health services. 

Allied health perscmel are the aajority of the health care 
% mtkfuiue . The^ wock in all types of care — priinary, acute, tertiazy, 
and chronic — and in all health care settings. Including physiciais' and 
dentists' offices, health aaintenanoe organizations, laboratories, 
fteestanding eecilities offering special aervioes, oniiulanoes, hone care, 
and hoq;>itals. The level of training of allied health personnel is as 
varied as the care they provide and the settings in %*iich they vatk. 
.'Jlied health personnel include both hic^y ertirwtfrt persoret and others 
with only on-the-job tnoning. Ihey work with widely varying degrees of 
autonony, dependenoe en technology, and regulation. 

But, there is a paucity of inforaation about them. Ihere is not 
even consensus on what the tern "allied health** neazw. OoBpared with 
nurses, physicians, and dentists, the allied health w ar kfo iue as a whole 
has been very little studied. Rxnpted by a cGngressional mandate and 
funded by the Health Itaeourooe and Services Adninistration of the U.S. 
Oepartnent of Health and Huonan Services, this study fay the mstitute of 
Medicine ms intended to answer the fdlowing question. First, what 
roles do allied health wooicers perf om and how will these roles fit into a 
changing health care delivery system over the next 15 years? Second, what 
will be the firture dmnand for allied health personnel and how can public 
and private pdicymakers ensure that the donand is net? Ihird, should 
these ooci^tions be regulated and, if so, hn/? And fourth, «hat sorts of 
actions flhould educators take to prepare allied health practiticners for 
the woir)(plaoe of the future? 

Ihe ocnmittee's reocDnendaticns are based on what existing ev^idenoe 
tells about mne vital charmcteristics of the allied health labor naxtot: 

o the ocqposition of the labor force— namely the predcminanoe of 
technically mnjeUaiL wonen with a service orientation 

o hig^y regulated pr^essions and woiic envirmnents 

o education p^uyiaiuB unable to ocupe/te effectively with other 
acadonic p rograms for limited rescuroes and sufficient nunbers of students 


- 2 - 

o aployni, \MiCexgoi3ng Maeping changes In their f Ijiancial 
inoentives, %te miit weUm hiring, ooqpensation, and w i cfa roe allocation 
decisions in the abeenoe of good infcnBaticn. 

1hrcui^h0at the stud/^ a Kjor challengpe fSor the oonBiittee has heen 
both to capture the diversity of allied health ooo^paticns and to devise 
specific yet enoanpassing reoopuendations for those \tto aust sake policy 
decisiom affecting allied haaJdi perscmel. TamrA this end, the 
oonnittee chose to fbous on 10 allied health fielwto. It used the 
folloidni criteria in the eelec^don of fields: that asch of the 10 be 
large and waU-knot^m that oollectively they span ths qpectrun of 
autonomy? ard that obUectively ttey vock in a vide variety of health care 

Ttm fields eelacted are dinioal labaratory technologists and 
technicians, dantal hygienists, dietitians, wsetgency medical personnel, 
nadical reoocd adtaiinistFBtors and technicians, occupational tharapists, 
physical therefdsts, radiologic technologists and technicians, respiratory 
there^ists, and speech-languai^ pathologists and audidlogists* 

Ihe ooBBdttee hopes that this report is only the beginning of a 
prooess that will clarify the place of all allied health oooqpations in 
the health care delivery system. 

Allied Health Bmonnel— 4iio are They and Miat Do They Do? 
Ihera have been aarty attvpts to define allied health and to 
categorize the occupations that oould be oo ve red by uriaralla definitions, 
lacking a satisfactory definition of allied health, efforts to dassif iy 
occupations have been fboueed on specific BMpectB of iiork and education 
suLi: as patient-oriffxted groqps versus laboratory-oriented groups, or on 
the level of aducation needed* The results of these atteqpts have not 
been enthusiastiaOly ateaoed by allied health practitioners. The 
connittee chose not to join in the search for a definition. The benefits 
of na)dng the term precise ar^ less clear than the benefits of continued 
evolution. The changing naturae of health care sakes soma practices and 
practitioners obsdets %hile opening \jp opportunities fbr the f omatiGn of 
nev groups. It is aore iirport^ that pracpnatisn centime to prevail, 
that old and nev groins draw -JoLt hmstitB they can fkon belonging to 
""allied health** than that a dif»i::^tion of ocnmon characteristics define 
the grc^p. 

Rather than define allied health, the conadttae choee to exBrnina 
policy^related rharacbaristics of occqpations that help eoqfOain how the 
fields are dif f«antly affected by changes in the health care 
environnent. These characteristics includes amount of autcncny in the 
vorlcplaoe, dqptnteioe on tachnology, substitution of one Isval and type of 
parsonnal fdr another, flexibility in location of esploynent, degree of 
regulation, and inclusion in accnditation staivSards for facilities. 



- 3 - 

Estinating Sifply and Denand 
In ocder to zeqpcnd to the cxngrassicnal duuge "to identify 
p r oj ec t ed needs, availability and raqalranants of various types of health 
caxe delivery systens for each ^pe of allied health pexsonnel", the 
oonmittee b'd to resolve issues of scope and apprc^^h. Given limited 
fimds and tine the ooniuttee believed that its greatest co ntri bution would 
be to try to clarify tiie future outlook, «hich is cxucial to strategic 
planning and policy, aXhex than systanatically assess the current 

Data Limitations 

Ihe oonnittee's ability to fulfill its charge was severely hanpered 
by lack of data, the result of a relatively low interest and investment of 
piblic zesouroes in learning about the allied health workfaroe. The 
oonnittee had to rely on data souroes that include seme inf onation about 
allied health, howtver inoaaplete and unreliable. The oonnittee afWMSfioi 
the existing data and oonducted hearings, site visits, and waricEhops to 
round cut its own ewpBTtiwe and help to understand the farces that will 
ihape th? ftiture of allied health ooo^ations. Ihe ocmnittee oould not 
make quantitative predictions of personnel shortages and surpluses, both 
because o£ tba usual uncertainties of oco^tional projections, and the 
absence of ttie necessary data elements, if enployers, higher education 
plaimerB, federal and state ctfficials, and others had soundly^^ased 
projections, decision making mi^^ be iiipcoved. 

The federal govemnent in its role as monitor of the nation's 
AODnadc activity has a responsibility to monitor the health %»r1cforoe and 
to inform participants in the health labor market and public policysakers 
of trends and developnents. Ihe %iark aC the Bureau of Health Professions, 
the Bureau of labor Statistics, and the CSenter for Education statistics is 
to be and diould be biilt vpan, in order to iapcove the data on 

aUied health fields, the ocmnittee »acmiiitaiJs that the S ecretary of 
Health and Human Servioes convene an interaoer^ tflffK fffT pe oaipoefid of 
rEPPBsgntativB& fton the Bureau of Tfl^^ ptfltlstics. the Center for 
BlliOtIm and other agencies that collect relevant data en the 

Billed hmlth waricforoi^, Ttijff tflP^ fagoe "hculd work teward IncraiisinQ 
the amount and iwpravlnci the aialitv of data needed to inform niblic 
PffllfT dmrMa^-^aJtegP h»t^^^ gpre managera. unions. WPffTWtiY? 
■nirtfnfiii n"» academic instltutlena abcut the mn«r< h«**i»^ ff^T^ jfTfltlTTP 

Td help iaplenant thim raocnnendatian and othns that follow 
ragoiring federal action, the ocmni'H -ftft rm pBiBTds thgt tlie pgp ar™HTt of 
Health and f^y-»r^ fi^<nM> ^infealn an attaniza ticnal focal point on allied 
hwilth nemcnnel to iaplcment the grant mroonnns reccmnen ded in this 
'MPOft. to TTmrlinnrft naasr^anaed work of the interagency data task 
foroe. and to facilitate oommnicatlcn between statt> legislative 
rrwn^tt^ ^ ff^/Bnl oovenmient. 



- 4 - 

FKtors lhat Af fact ths Supply and Dnanl for Allied HBzath PBrsomel 

A fizHt st«p in iDiclsntanding or projecting the future of allied 
health personnel, either as a qcoqp or for individual fields, is to 
u^Ierstand the yays in itdch certain foiroeB operating in the mviroment 
drive sqpply and denanl. Early action in r ee pc nec to these foroes can 
forestall the need ftar Bore radical csnections at a later date. 

The Qsrent Btploynent Situation 

Available data do not enable a xaliable estiaate of whether the 
a;|ply of practiticnere in the various allied health fields is in 
reasonable balance wl^ danand. However, during the coune of the stud/, 
the conmittee ms in contact with people ite observe various portions of 
the labor sarket fbr allied health practitioners. Ihese edooators and 
enployexB eaqproeeod increasing oono e m about the availability of students 
and practitioners. Educators generally report that their graduates find 
jobs easily. Ekcdoyexs report increasing difficulties in filling 
vacancies. Ihere are, of course, variations anong fields and localities. 
The nost fre(]uent reports of rtortage heard by the ocBi&ittee concerned 
physical therapists. Ibr other fields then vera reports of less severe 
shortages, or of hiring difficulties related to local conditions, changes 
in licensure, or a particular enployer's probloDS. The volatility of the 
labor sarkst was illustrated: at the beginning of the study some 
educators vera o o i CTrned about an oversqpply of clinical laboratory 
personnel; 18 nonths later thB concern centered on a growing difficulty 
in hiring trained clinical laboratory personnel. 

It is dear that seme changes in the health care systan ara causing 
shifts in enployoent patterns. Rnoqpective payment and otht^ efforts to 
control hospital utilization caused initial reductions in ho^ital 
eqplcymsnt for some allied health fields. For other fields the rate of 
increase in hoepital aqploynent slowed, and still othere showed a 
sidastantial inczease. Ihe growth of all sorts of out-of-hospital care has 
accelerated, creating some nsw sites for cnployaent of allied health 
personnel. Miether in the long run these translate into substantial 
n^^oBTu of additional jobs or Mrely a riiift in the location of oiployinBnt 
is an iaportant question not only for projecting descnd for alHed health 
personrisl, but also because ^hucm ara iaplications for the way personnel 
ara i^liinntert to practice in new settings. Moreover allied health 
practitionen vorking in tiwse new settings also raise issues for 
regulatora con o eme d with quality and for traditional enployere \to nust 
now coopete for « ^rsomel with enployera %ho can srmffMinpfi offer nore 
attractive saL4A:jes and working conditions. 


The ocnnitbM uMd tte bast ovailabl* data to Bake aasesanents of 
hov thB foroes that drlvci aifply and dnand for allisd health personnel 
vill affect allied health labor aarkets. Ohe intention is to alert 
decision-nakers to the kinds and ugnitudes of nguioet adjustments that 
they ehculd eoqiect and snoourage in order to sustain a Icng-^tenn balanoe 
tstwesi sugpply and dasand for allied health perscmel. 


- 5 - 

It is rha nature of varloBts to adjust eventually to change, 
Rnojectad inbalancses in supply and denand do not aaan that shortage or 
surplus will oocur. Rather, they signal that cnployers and potential 
OEplGyees sust, and prcbably will, sake adjustaents* only rarely do 
saxkets not aoocnaodats changes in sqpply and denand. But there are 
inherent tiiv^ lags and inef f iciencior in the prooess that can be lessened 
by public and private interventions. 

The future BB|>lGyiBent Situation 

Barring laajcr eocncndc or health care financing oontractiors, 
growth in the ranter of jobs for allied health vorkers will substantially 
exceed the nation's average rate of growth for all jobs. Uhless saone 
existing trends are aoderated, the flow of practiticnere into the 
wrkforce througlh graduation frm education piujiaas will be, at best, 

Fbr sone fields, such as {tiysical there^, radiologic technology, 
nedical record services, and oco^ticnal therapy, we foresee a need for 
decision saloere to iaprove the wozidng of the market so that severe 
iiribalanoes in supply and denand nay be prevented. Dqployere are already 
o mMjeLiwd about difficulties in hiring in some of these fields, and there 
are signs that health care providere are beginning to search for ways of 
aooonoodating new realities. Because sone of the aoccnraodatiGm are 
expensive and difficult to acccnplieh, the oonnittee is cxnoerned that 
inaction wby cause crises that could be avoided—health care services 
oould be disnfited because prcvidere of care are not available. 

For sone other fields, such as clinical laboratory technology and 
dental bygiene, there are factors that oould cause iratability in both 
supply and denand. For these fields the oarket is nore litely to sate the 
needed adjustnents and serious disruptions are less liloely to oocur. 
HoMsver, in both ot these fields there are unresolved issues ccnceming 
the level of perscnnel that will be allowed to perform oertain jobs. The 
%ny these issues are resolved oould determine whether major intelanoes 
will occur. 

Supply and donand for speech-language pathologists, audiologists, 
zeqpiratory therapists, and dietitians are e)qpected to be suffi ciently 
well balanoed for the labor maricet to make snooth adjiastzents. Zi^ kinds 
of increnental adjustments that make careen attractive and the ways in 
which personnel are deployed appear likely to maintain a state of 
eqpilitariun over tine. Nevertheless, for these and other allied health 
occupations, chancies in many foctors oould cause diseqailibriun. Ohese 
ftetocs include: health care financing policies, technology change, 
decisions idbout education prugiaas and regulatory policies. Ihose 
oc iioeiimi % ith reepiratory therapy, for ennple, rist closely monitor an 
educational capacity that has proved volatile, as well as changes in heme 
care reiflbursenent policy. 



- 6 - 

Our oondusifino libGUt the fotura outlook refer to the Icng tern and 
they are national in eocpe. For all fields there are lUcely to be periods 
of greater and leaser infaalanoe betwen now and tha year 2000, as n^l as 
local variation. Ihe objective of poli^ is to sake less painful and 
costly the process of edjustaent. A decline in quality of care, 
interruption or redactions of service, and curtailnent of investanent in 
new technologies and organizational fans (such as heme or ou^tient 
care) that sight isfmm the efficient of health care delivi^ are all 
possible byproducts of pereomel riiortagBS. Ihe decision to intervene in 
the labor aarket is sade through the politiaal process and reflects 
society's villingness— or lack of willingness—^ tcderate painful 
dislocations, m aany industries such dislocations are viewad as nomal 
and acceptable. Nblic policy actions have dencnstrated that health care 
is viewed differently. Ohe ocnmittee investigated how educators, 
cnployers, regulatois, and gcvexnaent can facilitate snooth %iarkin9 of the 


Ohe function of the education sector in determining the size and 
coBcnsition of the varkforoe is clear. Unless educators, in league with 
enployers and professional associations, are successful at fostering an 
interest in allied health careers among qualified proepective students, 
both the piograns and the allied health vorkforoe will weaken. 

Danognqphic studies show that the Uhited States population 18 to 23 
years old has been declining since the beginning of this decade and will 
continue to decline thrcuc|h the mid 1990s. Shrinkage of the college age 
population will make it increasingly difficult for allied health pi u jiai u s 
to attract qualified applicants. In addition, other attractive 
opportunities coqpete for that population's attention. Ihis suggests that 
greater attention will have to be paid to maintaining allied health's 
share of the traditional po61 of students, and that less traditional 
sources of students (such as minorities, older persons, and career 
changers) should be tapped. 

Academic allied health ptujiaiua must overcome the perception, and 
to some extent the reali*^, that they are eaooessively costly and that 
their faculty do not make a sufficient scholarly contribution to their 
irartitutions. Modest but strategic actions by the federal govemnent atn 
help ptogra n s deal with these prcblcns and conpete more effectively for 
academia's limited resources. Ihe ccnnittee l e uummaids federal actions 
that would provide a signal to others ite carry most of the responsibility 
~ states, education adtadnistzators, and enployers — that these prograns 
zust not be undervalued. 

FrdtHmoB of allied health educators can be analyzed in terns of 
recruitment of students, financing of prograns, and the mipply of 
qualified faculty. 



- 7 - 

FBced vlth incveased ocBpetlticn far stucSents, education 
instituticnB mst beocne craative in their approaches to recxuitnent. 
Allianoes %dth organizaticns also interested in racaruitiny allied health 
p apBorael Mist be toocgoA. Ite oonnittee therefore zeodmends: 

T?itrfntlTin 1nfftit"tlcns in close oollabaratien with molavers and 
pgQfeasieml flffffwiaUcns MMtt oraanlze for recaniitnent fff rmrimtT'i 
fftlTrtflltilff ^^e^lld be ecucht in less traditional ffTPTlrfflTTt Pools — 

minoritieP r^^At»r^ aHirlont-c f^ noay r^nnms. thOSe gm ^lcm^ jn 

>^^¥t^ r^np. am in fields lAera thev are uncllli j WMI I JU l liri . MTI 

iTtilYlfliwIfi vir>i hnnrtlmmltBr TTnnfllt^"^ 

One %iay to CK«ate aooess to a larger pool of students is to allow 
entry into education throu^ miltiplte ^laites. 

^i»<Mm»rf-#» mthiwivs to entrv^level txractioe ^lould he ancxuraaed 
irfwn r«**g<ble. State hi'thfT Mrmtlm rnm^J^tiner authorities and 
leaislfctive ocBHiittees e^miM ilgMt that education institutions 
facilitate mobility bptuBpn nr«mm<»Y finfl faWTP^am^te ppocnams. 

Recruitment of ■inocltj' students is a particular ooncaem for 
•sveral zeascns — adnaritieo represent a relatively unt^fjed souroe of 
aanpower, their representation in the population as a whole is incxeasing, 
and minority professionals are more likely to serve undereerved 

Ihere have been a nunter of attenpts to reczuit and retain 
minorities in health professions. Ihe lessens trm suooessful models 
suggest that interventions must oocul early in a student's life and 
oontime thrGuc(h the imwdpmlr career. Ihe major souroe of sifport fktxn 
the fedeikal govetnnent has ocne frcn the Health careers Opportunity 

The coottittee zeocnmends: 

Mlnaritv lecniitMent efforts must begin befara hirt; sAool. 
fttTffi^iT? Ipstltutions miffT VTffT academic succort seryloes for getep*ixcn 

nnd ntrlT tp tganote ct^^iimai mgfrmtYi TV mrmwl in the icr>j run. 

these efforts TMfft bB IP*^ int^n^i mi^ir^ ff^yTntilTTl 


7W» nrmwnH^mm mnOarBea the efertftetivBS of th> ItenH-h CSreeiS 

Caaortunitv Rooram mODP^ and believes that funding levels nust i»»bi- 

Allied health tttoyraus are vulnoable to closure because they 
aifjear to lag behind other prujiaius in oontributing to the academic 
standing and financial health of the institution. The coanittee made a 
muter of raocoBendations directed to several aefiects of this problem. 



- 8 - 

Ihe overall strategy Is to put allied health iiLUjiai u b cn a nore etytal 
footing with other acadenic prograns. 

m Qtdar to ihanQB the «abilltv of alHwrt health frtiiratlm. 
ImtlTflff Blftinff th* ^»««rieBn Society ^1H*>H H.»*i»b 

uld inwMitio ata irjflff In r^«daiiic iiistituti<*e have 

finnTirTlnl fawf 

faculty DrTlff*-1m PlmP- earteneien aai 

national areBni2ii»-<m^ ttieulA Ulan MA igyteahryw to heln 

ainate infonBatien. 

ttitil ca»Uhle alternative miUlTrlWft dewelnnwd. thft fwteral 
SPvemnent and other third^partv naivers Acu3fl »n<nhi*<n nvrr^thf 
gplBtaurBenent lavels ^ ^p^n^aw. nf Bgmrt fCT* BlInlCTl gA'Hlti^i 

The oonnittee found that in sone fields ahortages ware inhibiting 
esqpansion of education capacity daqpite strong student and aiployer 
denand. Mora generally thexe is a peroepticn faculty are beocoiing 
^<ie«^acnr'4»»<rf ftm dinioal practice to thB detriioent of students' 
preparation for the wariq>lace. This is in part due to the academic regard 
system which does not value patient oara hiqjhly. Attention to faculty 
skills, however, should not he ait the eoqpense of pt uyie as in solidifying 
the research Unae^iraiings tliat guide everyday practice. 

The federal 

ultv develocment 

grants in qll^fffl tiffllth fields esimr1a1|Y tihf" faailtv availability and 
lack of cUnl^l mfPfrtigft InhlMt the production of entrv^lcvel woiters. 

the aeientiflff teny* Qf nniflrt hftfllth nractioe. 
institutions with mc 

Iff TV^rM tft ffltfflir?? 

■Jo aaocBPligh this. 


j^omrarotiia t^i d a ^ 

sider develcpina 
The ocnmittee 


to support these 

Private foundatiene rtiould mgimrt ffTPtegB fear alHf^ IWfll^*' 
studies and policy , tttfin universitv-based Qe ntftnT WI U provide a 

■fffffffinffftfii h^''^-^ ■^fflft rif**rctl. and YMT^n rescuraes utilization. 

instituticana offering allied >w^1tll flfflrifmk PTVP™ rfimld reward 
and enoougage facult y nUn^i^i nnr^oppB, clinical practioe that 

.<n« nr»frt-^»nne ahculd be « ~n]irgnent and criterion for 

Health Chre institutions 

Health care cni>lcyer8 directly generate demand for allied health 
wcxdoera and indirectly affect simply isy the conditions of enployment that 
they offer. 


Ihe aanittes zeviswed the available literature to djtennine the 
■ofrts of activities that aiplayers cxuld undertake to enhance the supply 
of allied health irottarB by arcing a career in an allied health field nore 
attractive to pecfile choosing an aoaiaticn, and by increasing retention 
rates. Wm studies of allied health were found. Most relevant work is 
finan nursing, liiere inbendtteit ihortag^ have fbcxsed interest on what 
it takM to soduoe lurse turnover. Ihe literature bbIobs it clear that 
epployers are able to affect eii ttan oe and exit rates. Even a mell 
increase in tmire has a significant iqpact on the size of the wockforoe. 

The ocnnittee reccnnends: 

Wmlovwre itfinilfl strive to Iwmfff tlW paaolw of alH*rf h^i^h 
pri>f?h<<^4«i«rB «^*T^in^ P*T^* hfffflth and prolenaina their 

mM-^rtm^ »/> ^ifiOs. Sana ^'^^'"Iff Increasing ooBPensatlon. 

mni denelcpinm wmf*Mnim»n tmr rt-miUm. l^lrtygrB also BbnilH ^ff 
new labor pools that innl^flft mm. piinaritlas. career cfaan aers. and 
with handic*ffr<TH T7^<»<^ 

OsGpite the reluctance of enployers to raise pay in a 
cost-oontained enviranent, if iri»rtages occur oonpensation will increase 
as adninistraton are oonpelled to try to attract new entrants into allied 
health professions. Ihis «rill nto allied health personnel a anre costly 

ThB ocnnittee found little evidence of the strategic planning and 
imm\ I h that oould help aployers effectively use allied health 
pcactitioners and at the same tine preserve quality of care, working 
within regulatory constraints and avoiding the professional resistanoe. 
Nowhere is there a substantial body of rabearch to inprove the 
effectiveness of allied health practitioners' activities. 

Available data indicate that in nany allied health occupation 
entry-level pay is currently oonpetitive with other ccnparable 
occupations, but allied health salaries ewer the life of a career are so 
ocB tir e ss ed that there is no inoantive to rsnain in the occqpation. 
Effective use of aanpower will neoeasitate ooepensation incentives to 
incanease tenure, and work arganized in a wcy ^t uses the greater 
eaqperianoe of the aore eoqpcnsive aoriaers of the wockforoe. 

Ihe ocnnittee reconunds: 

Health oara m/iAitn and nrtminlstnitnrR whculd seek innovative 
ways to cjiamel limited allied health rWWTPffff tft flrtlvities of nroven 
benefit to ooneiaaars. Agencies ich as the thtlcnal Qanter tar Health 
fiervioas WBeeniTh and the Health ttre Flnanclr-i Aininlstretlon ehnild 
mnsor rasemrh and tertmDlonv asBesmwnt to r- jre that alH«rf hAni^h 
eervloes are both effective and otoanizad efflc^/Hy, ^«ioff<»^^i^^ 


- 10 - 

MPlovBTB. unions, aasrwdltlm acMnclag. and pfrofeagleral flffffOTlrtim°. 
■hWld flffg^flt. in flififfl^^"*^^"? **search findings and prwidina technical 

fttmist-MT)/^ In iTHTlMBntaticiii 

Baalth CBxm aanagacs will not auocsaed if they axe alona in these 
•ffocts. Urn educators and pcofaasional assocdations, «ho provide the 
basis for practiticneni' goals and aqpirations as well as technical 
knowledge and skills, Mat also paxticipata. Bducatora, cnfolcyexB, and 
professional aaaocdations sust sngagie in a xagular intexcheuigre and 

Chief eMBCutive offiosFB. >«iw»in rm^vf^^ dirtrtCTS' and other 
hftnlth nnTt> jidm<n<«Mniii-/w^ ».tcrt> A^yelcp sethniff fffiT ftfffflTtiva utilization 

»ho i»H«t-4rj ■g^]Y fff nllltil tr*^»h i?fr''^*i^- SUA iflfltJiinlff mifft Br~ 

m„^,^M^\qi^ vith rmu WBVB of eff ieicntlv araanizina the work 
Mrwi dlitrlhrtlm of lltfrgr mrr" ^^''T ^^vels. al%wvB ensuring that 
CRialltv of care is not 

aifxIoyexB and edacatoca aust focge a xelatlcnship to ensure that 
g raduat es axe not finistzated fay unrealistic e)q)ectations about «hat their 
vatk will antail and oiiiloyars do not ignore ^ needs for career paths 
and professional stiaalation. To be suooessful this effort vecpires that 
eaployets and educBtors try to understand each others concerns, 
cons tra ints, and the prassures exerted by a changing evnixcnnent. 

local levi»lff. vill hft 
flle? lea ders of 

fflgB Bust enaaoe in 
iimrove the ooneguenoe of iploMBent and 
lAlA rtiould take place at the state and 

lb facilitate this interaction, the oannittee leaamieiMla that state 
?1lBh IPffriffll Mlfff ti^Qse primary purpose would be to 
in the education and aiclovinent of allied 

licensure, OKtification, and Accreditation 

Ohe oonnittee took a broad view of the diarge fton Oongress and 
examined the full array of regulation of allied health personnel, 
including state licensure of indiviaoals and health facilities, 
certification of individuals by private ccgenizations, the iii()OBition of 
standards by third-party payvra, and voluntary aocxeditation of aduoation 

Oollectively, these ragulatacy Miiminii affect the size and 
ctiaracteristicB of the allied bsalth wockforoe. Ohey affect the 
functioning of the labor sarkst for allied health workers by defining vho 
■ay enter the various fields, by deteraining «t» has vhat degree of 
control over health cava saxvioes and dollars, and by constraining the 
range of staffing options cvailable to mfHa^m. Ohey provide identity 
and legitinacy to newly energing ogofiations and their nenbers. 



- n - 

Oocxfiaticnal liomsurB is of rwTtlnilar oonoem to the ocranittee en 
Mveral grounds, fm tt» Bost nstrictivs type of ragulatlcn, it grants 
soocluslvs contxol ov«r warn hsalth ■ttvloas to one type of vcrf'jer. ihe 
oomtittee oondudad that liooMun is oostly and owberscne and that its 
•ffactivmss in profbacting the public is far trauk dmnstia tod. ihe 
•ff oEts in a naioer of states to rafdra the ngulatnty process are 
•xxuraging, particularly the evbluticn of "sunrise" critr^ia for 
evaluating ths need to regulate nav oooi;|)aticns, which the ocnnittee 

zncraasing the participation of the i jiLic in the regulatory 
also is a positive davelopaBnt. Ihe oonnittee seocBnands that 
states ahould s ti w>j U >«> the aooountability and broaden the public base of 
their regulatory statutes and prooaduTM. In the near tern, the oonnittee 

lioanelna boaras i^niilrt rtrww at least half of their ir^«*ii»i^4p trr^ 

nlt-miAm *hm Hnwnoirf onnyi.»<r«. iM«*^t^ «hruld he drawn frcn the nihUe 

nwlMUtY ^ liamaura statu 

iihle without undue rlA of ham to p,KHn, 
wiH-^wia taaths to Hcensure or 

ovwrlaminn wrmm nf nractioe for seme lioanap^ 

m of conoems rbout tte fiiture availability of udequate 
ludaers dt allied health pennnel, and in lig^ of the rapid changes in 
health care delivery, lioansure mgpasm to be inoonsistent with the 
flexibility that will be naeded. The ocmnlttee believes that states 
ahould try to find alternatives to licenwre. Rmfessicnal gro^s should 
work toward strong title oartif ication, devoting their efforts to 
convincing the piiblic and the industry of the aid«itiai's value, as 
oertified public accountants have done in their qphere. 

The ooBmlttee leuaaiaids statutorv oertlfleatlen for fields in 
lAleh the state detentdnes there Is a need for reijiulatlen fcf^im* ffilff 

fom of raaulatlcn offers aost of the benefits of llaensure but feuer of 
its posts. Madleaie and other thlid-Barty mygrB ahould fKTTflBl; fftfltt 
title oertifloatlen as a nteraailsjtiy fffT r8lir*ii^~««n» ^liaibiHtv. such 
Qertiflaatlen can and ehnild haw^rt m «Bmi<ni*»<m« mtA ^tfify 
ellyibllltv criteria 

The oonndttee was um>jeni e d that jurisdictional strugglee 
health ocofiations over scopes of pcactice and over referral and 
supervision rec|uireBSRts are conducted without a body of xe^iearch 
literature or the infomd judgpamts of knowledgaadale, disinterested 
parties to guide those decisions. Masent such inforaation, there is 
oonsidsrable risk that dacisions will be eade on purely political and 
economic groinds. It ves ths coBnittse's view ttiat tiie federal goverment 
ahould take an active part in developing the necessary evidence for use by 
Ite authoritias reqponsible for these decisions. 



Lth KDf— slom for othar fat^m fffTTfll points for 

Bprinl irlTTi rmmimi imninirinn tn mmm itrfacttvaiv the evidencae 

Thin hnrtv. in cacnsultatlen with ot^r tMfffTtff 
and intflgaatgl partlfla. Umild tm^/W.- <— nog ef rlA. e ost. quality, and 

Hhe oomittM choM to dsvote qpacial attention to long-tern care 
for a luter of vaaaonr. Ohe aging of the population and the need fbr 
long-tarn oare for the elderly in a najor fccoe in future denand for 
allied health Mxvloan. Deapite taroad ocnoem about the needs of the 
elderly there in no certainty that the currant financing eyetans mable 
ptoviderB to satisfy those needs. Further, beoauae Icrig^^em care 
seqoires both therapeutic and social aqpport serviceo, it affords an 
opportunity to eKamina insum aurrounUng tiM interaction of allied health 
practitioners %dth other profeesions such as nurses as well as with 
wocters having relatively ninimal fomal edocation — an iaportant qccup 
of mrtezB cn which the connittee wished to fxus attention. 

Allied health pcactitianem relate differently to their clients and 
to other health care providers in each of the three long-^tem settings 
studied ~ nursing honas, hone oare, and rehabilitation facilities. In 
nursing hones, nininally trained lurse aides are often ttm prinary 
caretakers with the nost frequent patient contact. Reoent congressional 
and Health care Financing Actadnistration's actions to increaae aide 
training in a ntap in the ri^ direction. But, in the future, aides will 
require a hicjher level of training to link then noce effectively to 
nursing and allied health pemomel in the delivery of handn-cn care. 

In raooanitlcn that the areatast amount o f diraet patient contact 
and care in lono^tam care settings and mxprtam is pravitjfrt IBTfKnnf 1 
at the aide leval. the ffriflml gfTffl n™nt othar rasaaanaibla 
gcvemnental agencies Aojld raaiirR edimatinn and traijiing tg ralw thft 
kncwledoB and skills of thmf Ftimmel- Danenstratlon pre lects ehould be 
funded to enocuraoe joint afforta by «><.v^t^ pnd amlovepe in ereatina 

types of organigaticne that provide longr-'tem care, such as 
facne health agencies and nursing hoans, mmt ooocdinate a wide array of 
servioea needed by fragile dlentn with aultipla dinccders. Mi^iandled, 
thin can result in ftajnait ad oare, -rmiat'timac dqplioative efforts, and 
often less than optinal uee of each service. OoUabarative team work by 
the care providars would iapxwe the quality of oare by helping tean 
nodaers to better understand each other's roles, ensuring aiprcpriate, 
coordinated care, and nic^ even reduoe staff turnover by increasing the 
involvement in the job of each team 


- 13 - 

TSm acnnlttM, thttnfcn, MocDnmds that 

miy^4i>»^ wj^^ etimnifi illn^^ rin ntit fall vitJiln ttW tmiTllnrlWr TTf HTTY 
■inglt ^^*^^rMntr ||dp<n<«Hr»»r^ and cara ooarJlnatarB In Icanq^bmn care 
aattlnpi Aou> d d gvri>c3D mt^ ^i^ "j^ ans for anaurlnq tfa *» rii^ rHomal 

Mora gmcally, allied haalth varfcars in all longrtem oare 
Mttinga nnd qpacial pra|)aration to taloa cara of patiants with chraiic 
iUiMM, to undamtand tha p^choXogioal aqpecta of aging, and to oonftofit. 
disability, daath, and drying. Ihisrafora, thu agmit»^ ^'^iifiil iY thnt 
all alliad h^1»h iiAin^t.lm find lapainlm raroar^ jyrl^rtff aubstantiva 
QontairA and practtoal pHn<«il ^agpcriflnQa in tha caara of the ctironioallv 
m nnrt fWHli 

Oolliibarattva Action 

TjJoen as a vhola, the ccnnittoe'a zaocnnflndationB are designed not 
Barely to advanoa tha xola of allijl haalth oooqpations, but also to 
lyaaeiva tha ability of the haalth carv% lyitcn to o onfta t t the pcoblans of 
ttm raoct daoada. In drrfting its l a uummii ations t^^ coaadttae ims 
cognisant that no one antity in the piiblic or private sector nov has the 
power or naponsibility to determine ^tether allied haalth education and 
pcactioe vill adeq^^tely zaqpond to the challange of changing pattens of 
illness and care raqoixnants. Ultinately, collaborative action %dll be 
mioirad. Nona of our raocanandations is self-iaplaomting. Each 
requires a principal party to convince othere to join in their efforts or 
to acoade to alterations in traditional vays of operating, idhether in 
educating stucSents, delivering services or supporting professional 



A coifuterized March of tte nation's nawspsqpexB for the smth of 
Octcber 1987, found tte tarn "aUi*! health" cited In two stories. At the 
sane tine, there were 443 veforenoas to nursing anl over 500 to 
i:»V*icians. Ihe individual fislds that nocnaUy fall under the heading of 
allied health ftaed only soBBwhat better. Xtiysical thencists were 
nentioned in 21 articles, oooupational then^tists in 8, Bedical 
tachndlagists in 3, and dmtal feygimists in 7. ihe ecaxcity of such 
referanoes reflects a lade of pihlic oueraness of «hat allied health 
practitioners do, and the fleet that the tern has little or no neanina to 
the public at large. Evm in the hear h oare ooBumity there is 
oonsiderable oonfUsien about which fields ooMtitute allied health. Vbnv 
people who deliver allied health servioes or who educate its practitioners 
hove long been dissatif ied %dth the tern. But this has neither lead to a 
zeplaonent nor a ccanonly accepted definition. Ihe only consensus is a 
distaste for the pradsoessar tern ■^araaadical.'* i^ppendix III provides a 
sanple listing of job tiUes and aUied health fields that midht be 
included in the broedast definitionB of allied health. 

avported by a grant fkan the N. K. KeUogg Foundation to the 
Amerioen Society of AUied Health Professionals (ASAHP) in the late 1970s, 
a National Omission on AUied Health Education tried to forsulate a 
oonseraus definition. Ohe ocnnission's struggle with the ccnoept is 
reflected in its definition that foUows a six-page discussion: ••. . . 
all health pereoenel Marking toward the ocnnan goal of providing the best 
possible sendoe in patient care and health pranotifln." (National 
OomiLSsion on Allied Health Education, 1980) . Ihls definition does not 
draw h m m flw r ies that eaedude groqps of health care providers, nor does it 
describe onnonalities of task or education that define the fields to be 
included. Rather, ttie oomnission chose to focus thenatically on 
"aUianoes that need to be built" and "the ooUabatative approach to 
providing health services" as part of a team— an approach that has value 
when the purpose is to bind together a disparate gmp of practitioners. 

Ihe definition offered by the Oonnittee on AUied Health Education 
and Acxxeditation (CMIE^), a body that accredits nearly 3,000 education 
prograns, suggests the sensitivities involved in the designation of the 
fields that oonstitute aUied health. GMIEA defiras aUied health 
^actitioners as, 

... a large cluster of health care related professions 
and personnel whose functions include assisting, facUitating, 
or ocnplenenting the irork of physicians and other ^)ecialists 
in the health care syston, and %ho choose to be identified as 
aUied health pereomel. 


Dftf initiom of alliid hnlth vary doe to its changing nature and 
to the dif faring pnqpectivas of those «ho attaB(9t its definition 
and becaiMS oartain ndically related but traditicnally parallel or 
^ " y ci ' iiait ooou|)a(tionB prefer idantities indepandent of allied 
health: nursing, podiatry, phamacy, clinical psychology, etc. 
other ooofietions aey or my not regard thanselves as allied health, 
dqpanding qpon their varying eiro u as ta noa e , e.g. , nxtriticnists, 
apeech langiwyi pathologists, audiologists, public health 
apecialists, licansed practical nurses, eedioal resoaxxh assistants, 
etc. (CMIEA, 1987) 

CARET'S discussicn wrhasises ttet there are two approaches to 
defining allied haalth: the first iVwi i lUwi groups or characteristics of 
groups that fall vithin oartain ill-<]efined boundaries; the seoond relies 
en excluding gca^. 

In its 1979 BBPort can Allied Ha^ lffl PBTgrnnftl the federal gi M i m ui e nt 
adapted the latter view. It attanpted to vinm fkcn 3.5 ndllicn vorkers 
those in fields ttmt oana under the federal purviev as allied health. Ohe 
criteria axdulad thoee (a) treated eaparately by legislation other than 
the allied haalth authorization; (b) havin^r general rather than health 
qpedfic asqpertise applicable to other indu^ies; and (c) perfomdng 
functions that raqpire little cr no foraal training in health subject 

OSus, in additicn to physicians, noraes, dentists, cptcnetrists, 
podiatrists^, pharmacists, veterinarians, and other independait health 
practiticners, the authoocs of the report excluded: 

~ professicnal public health pexscmel; 

bicmedical ivfloaiih personnel; 

~ natund and social scicntisfs %ioiidng in the health field; 

~ nursing auxiliar^^; and 

— ooo4>ations regoiring no fomal training (U.S. Department 
of Haalth, Education, and Nelfare, 1979) . 

- 3 - 

Deqpite the continiijig debate about definition end boundaries, sane 
groups of practitioners have ocne together and uneqtiivocally call 
thensMlves allied health personnel. The federal psxxpiam that sinported 
allied health education provided the impetus for aggregation of these 
groqps, such as oocqpettional therapists, clinical laborataxy 
technologists, and der.tal hygienists. Ihey ooalasoed in acadenic 
institutions under schools of allied health to benefit frcn 
maltidiaciplinary interaction and educational efficiency, in health 
servioas settings for reasons of peraomel adninistration, and in the 
professional associations to attapt to Influvcb policy, collect 
inioftsation, and public scholarly pepers on iasuis of interest across the 

This coalescing is by no aeans ocnplete; there are nany acadeodc 
piXMjtam outside allied health schools, health facilities that do not 
operationally recognize allied health as a useful groiplng of ocrupational 
oategoories, and strong allied health proftesional associations acting 
independen t ly of each other in the policy arena. However, the reasons for 
the diverse groips to ocne together under an miairella title main valid. 

The ooamittee choee not to engage itself in the eearti. for a 
definition. Ihe benefits of Baking the tern precise are less clear than 
the benefits of oontinaad evolution. Ohe chimging nature of health care 
■ekes some practioes and practitioners obsolete vhile opening up 
opportunities for the fomation of nev groups. It is more inportant that 
pragmatien continue to prevail, that old and nev gra^s draw what benefits 
they can frcn belonging to "allied health," than that aocurate descripticn 
aC ocenon characteristics define the 

lAddng a satisfying dBf inition oC allied health, nany grotqps have 
tried to ij^pose mder %dth a varieity of classificaticn sctew. One stud/ 
classified practitioners aooarding to their departnental affiliation and 
suggested the use of oategpries such as dental, dietazy, emergency, 
diagnostic, therapeutic, and visiGn care services. Another study 
entivisiml sane cacosscutting features across types of work. It 
reocenended classification aooarding to petiwt-oricnted, 
laboratory-ariented, edministZBtion-oriaited, and ocniunity-oriented 
gnxpings (National Advisory Health Oouncil, 1967} . A poll of 
professional aseociations urived at three ^"clusters** aooording to job 
function: prine^ cere vsoicers (including Mdical, dental and nursing 
personnel} ; ii^alth pranotion, rehabilitation, and adhninistration 
persomal; and test-orientad iPorkerB. (National Oanmission on Allied 
Health Bduoation, 1980} COLearly there is no ^"correct** taxonony; different 
classification sctonnes oqphasize different eepects aC allied health jobs 
and persomele Ihe different m^^haar^ oen be used to serve different 
purposes. Rather than raly on a sii^ definition or scheme throi^^Kxit 
the study, the ocundttee pcefers to ftntvisire the fbllowing 

ERIC ' 30 

- 4 - 

characteristicB of allied hMlth fields. Each hlc^icfhts inportant 
poli^ralated ctanctaristics and helps to mqplBin hov the fields are 
differently affected by ctengas in the health oare ensrirGnDBsnt. 

!• latvel of mftrw^gmr^ som fields have a history of practice 
without disnect eqpervision, vhile others are strugpgling fdr a vaasure of 
indspendsnoe. Nmy can %iock only as esployess in «f)ervised settings. 
Ractiticners %t)D can attract their own patients oan reap the financial 
xeuards of the piUic's interest in and villingness to pay for their 
services. QUees health oare peyera are willing to rei]±urse allied 
health practitioners fdr their services, and unless the practitioners are 
ftee of regulation that zec]udres on-site supervisicn of a physician, 
independent autonoBBUs practioe is not possible 

2. Itwn^llfni f ^ technoloav Jn a health care system that 
ffcequently adapts rmt anchines or techniques, individuals %ftio vork with 
only cne sachine say loee their jobs as nev technologies arise. Ihose %)ho 
beocne broedly involved in one or sare technologies are less vulnerable to 
obedescenoe Ihoee involved with technblogioal imovaticns that are 
coning into videepread use should belief it fkon strong desiand fbr their 

3. fiibsUtutabilitY Oooivetions vary on %tettier tiieir **turr" is 
vell-oarked and protected. If vorkers fron two oooi|)Btians or two levels 
of the mam ooo^iation oan perfom the same functions, the imrkers vho are 
paid nofre or «ho are sore specialized say be displaoed. If aore hic^y 
trained markers are viUing to work for the same wage as those with less 
education the lower-level practitioner ny be displaoed. For Msployers, 
the ability to substitute one type or level of personnel %dth another nay 
be helpful vhen the supply of one type is ti^. 

4. Flexibilitv in location Pf fllPlgWIBTt Those %to cani^ in a 
variety of settings are less vulnerable in a job narket that rRspnai^ to 
altered financing inoentives by ^fting the location of care, and 
contracting the anount of oare provided in sons settings. 

5. Dnrgft pf reaulatton If a field is hlg|hly regulated (licensed 
by the state, titles protected by oertification, or regoired to register 
vith a goverment agency) eB(>loyers are constrained fron hiring anyone but 
vockers fron that field to perfom a function. These VDrkers are 
protected ftoa substitution by other persomel. Ihe siiQply of vorkers is 
likely to decrease if the reguirooents for entry into the field are 

6. teduslen in imnrnHtntlen car oertJf<«ii-<m ■♦•j»rrt>irtte m order 
to noeivs aocrsditatlon or certification, a health care facility nay he 
ragoiivd to aoploy practiticnars in certain fields. If so, desand for 
these wooicBrs will zeepcnd to changes in the luriaer of these facilities. 



- 5 - 

Ihtcug^icut the study, a najor challcngre for the oonidttae was to 
both oepture the divanity of allied health ooo^iatiora and to deviae 
qpecilic yet anocniiaasjiig tatxenandatiora for those «ho oust nake policy 
dacisions affacting the pcactitioners' rola in the health care system. 
TcMTd this and, the aoBnittae choaa to focus on 10 allied health fields. 
It ussd the fdUawing ccitaria in selectng the fiaUte: each of the 10 
ihould bs laxge and wall-kncMni oollactivaly they tfmld ipan the nectrum 
of flutouoDy; and cxillsctivaly they AaoiA include p ictiticners who work 
Inawlde variety of health caze aettin^B. ftiere suitable, however, the 
report will draw qxn infanaticn daout oOmt allied health ooapatiora 
that was provided to ttie oonadttea. 

Ihe fields aelact&l were clinioal Idbocatocy technology, dental 
dietetic services, anergpicy Badioal services, aedical zeoord 
aervioea, conya t io n al thangpy, pliyeical therapy, radiologic technology, 
re^>izatocy therapy, and speech-language pathology and audiology. 

Ihe final chapter of this report includes an CKamiration of the zole 
of nursing aides in Icng-tem care. Nursing aides are not often included 
in definitions of allied health perecmel, but are hi^i^ited here 
because of the cruidal role they play in patient care in many long-tenc 
cere facilities, and because the oentrality of their role aakes their 
relationship with allied health personnel very iaportant. 

Ihe diacussion of aides in the final cheqpter also helps faring 
attation to seme groups that are less (tiwnwaad in the remainder of the 
report than the oonnittee would lite, ihese are tiie louer^level 
personnel, often called technicians or aides. Ohese practitioners are 
fre^iently on-the-job trained, artiinnted in Aort vocational p iu jianai or in 
one-year certificate programs. Because analysis of the ynuM j iit and future 
wpply of practitioners depends heavily on data ftom education 
institutions, and these are not available ftar lower-level personnel, tne 
ocnnittee %ns unable to sate the sane ninnfiiiiieiiit for thaaa groupe as for 
come other allied health groups. Moreover, the jobs and tasks of 
la«>level pereonrel are not generally clearly delineated, and even their 
job titles can be ocnfusing. The ocnnittee was therefore unable to 
evaluate trends in deuisnd or the forces that detennine the sizply and 
demand fbr ICMsr^level Fcactitionars. 

Gbservations aade by a oonnission aasenhled by the American Dietetic 
Association (American Dietitic Association, 1985) to exanine their 
profession help eoq)lain i*y study of lower-level personnel is difficult. 
Oaring World Itor n, hi^ school vocational prograne, adult education 
prograna, and hospital education pcograns began to train dietetic sinport 
persomel caUed food service eKpervison. To this array of training 
sites was added ajcrecpondenoe courses developed by the Anmrican Dietetic 


- 6 - 

Association (ADfl) in the late 1950s. Itien it became a p pa rent that a more 
hi^y-edhjoated support perscn imb naecSed, the dietetic technician was 
cxeated and trained in food servios Banagenent, rutriticn care or as 
gansralists. Ihenupon tiia food supervisor title ves changred to dietetic 
assistant. Altiiouc^ in 1972 ADI^ publiited p reyra m essentials for both 
oatagprles and began fomal rwimt end approval of edaoetion programs, in 
the sane year a study comdseion found e need to define the tasks of the 
tuo fields* A dsoede later en attwpt to detemiine the nunbers of 
dietetic euppoct persomel failed. Many pectleuB %PBre found. For 
eocanple, ymimru identified as dietetic tedmicians were graduates of 
dietetic assistant or other programs. At tite same time, the title 
"^dietetic essistant** ws d oc med inappcqpriate because these practitioners 
often did not assist, but managed. In 1983, ttieir title wis changed to 
dietary manager* In tiie sane year, partly because they could no Icngier 
differentiate the roles of the two ^fpes of support persomel, the AD^ 
%dthdrBW troB ttm pttigi ' a m of approval of dietetic assistants education. A 
menfcerehip association of dietetic technicians and assistants took over 
this function and the ADA is lest the dietary managers becGoe 

isolated frcm the zest of the dietary field* 

Zn sum, dietary sif:port persGnnel are both formally and informally 
trained, their roles are ill-defined, and their titles are in a constant 
state of evolution. Moreover, the ADA also notes that dieticians often 
use Afpcrt perscmel for clerical rather than dietary tasks. 

Ihe oGmcittee is aware that aides, technicians, and ajssistants play 
an isportant, if scnetijBas ill-defined, role in the nation's heath care 
system. By focusing on nursing aides in the final chapter of this report 
it hopes to give the reader an inpressicn of the vital nature of the work 
of this group. 

Diis chsqpter briefly introduoes each of the 10 allied health fields 
covered in the report and outlines their evolution.^ Oie developnent of 
two fields— perfusion and cardicvaacular technology— is traced to see if 
developing fields tend to fdlov the same general pathways of established 
occupations. Appendix IV offers the ccmoittee's best estimates of the 
current nonbers in each of the 10 fields. 

CSLinical laboratory Technology 

dinical laboratory personnel perform a wide array of tests used to 
aid physicians in p re v en t ing, detecting, diagnosing, and treating 
diseases. Ihe generalist medical technologist is the most widely 
reoognized practiticner in this field and the one focused on in this 

'ihe description of the allied health fields was drawn in large part 
from a psper prepared for the ooranittee by Bdnurd J. McfTeman. A list of 
historical source material is contained in app^idix VIU. 



xtfOKt, but tiwze an oan/ ^lecialtles idthin ^ field including blood 
boidc tachnblogy (the pciepanition of blood for transfusion) , cytotechnology 
(the stud/ of bod/ calls) , hematology (the study of blood cells) , 
histology (the study of hman tissues) , aiczcbidogy (the study of 
BicroorganifBDB) , and cUnioal chonistxy (the analysis of body fluids) . 

ftactltiflnBTB fall into tuo broad oatagories: beooalauseate- 
prapavad technologists and associate Oujiee and oartif icate-prepared 
technicians. TKhnicians peifui a rautina tasts under the supervision or 
dixBction of pathologists or otiier physicians, scientists, or coqperienoed 
aedical technologiBts. Asaociate dafjius i.iLi|jaied technicians 
discriainate bet w ean sinilar itans, ouii a ut erxan by use of preset 
strategies, and Banitar quality oontzol pmyiaas %dthin predetemined 
paraneters. Technologists p arfom ooniaex analyses, nke fine line 
discrlBinatlons and c xjiiut arrors. Ohey are able to recognize 
intexdepondency of tests and have knowledge at physiological conditions 
affecting test results in order to oonf izn tiuse results and develop data 
useful to a physician in detemdning the presenoe, eoetent, and, as far as 
possible, tile cause of rtlswnwft (GM&a^, 1987) 

Zn the United states, the first clinical labocatory «bs established 
in 1875 at the University of Michigan. Soon thereafter, labaratories were 
establlMMd at other hospitals. Riysicians specializing in (Athology vere 
r espo ns ibl e for these labcratcries, but since the vatk. was often routine, 
tiwy soon hired nan-physidan assistants. 1900, there vexe 
approodaately 100 techniciana in labaratories <uxund tiie country. Demand 
for labotataty p erson n el greatly increased viMi the esqpansion of the 
health care system during Morld War I. Ey 1920, there were 3,500 
Uboratoty technicians in the Uhited States, hedf of «hom were feoale. A 
census taken two years later revealed that 3,035 hoc^itals had established 
clinical labaratories. 

All early technicians were trained for their labaratory role by the 
pathologists for \tai they worked, m 1922 a training 
Mfcablirhed at the Uhivorsity of Mimsctae Today a bachelor's deginae 
%dth a sajor in medical technology, biology, or chenistxy is the standazd 
prerequisite for an entzy^level job as a technologist. Kadical technology 
piujiaias (offered fay oolleges, universities, and hospitals) are based on 
ocnsiderable oourse work in the pnysical scimoes and sathenaticB--often 
closely lesabling the pre le di o al curriculian-^and at least a year of 
clinioal training. Hospital piugiauB are usually affiliated with 
universities %Aiich grant the aoadenic degree. Technologists can also 
beoome recognized as such tiuxu^ a federal certifying exam. In 1972, the 
federal govermmt establitfied its own testing pro gr am to certify 
laboretocy vorkers and make thn eligible to provide rei2±urBable services 
in HBdioare end Itadicaid prograss. SucoessfUl candidates are recognized 
for Itadicare and Nadioaid pu rpo ee s es clinical laboratory technologists. 
Madical technicians may be graduates of two-year pmyiams in connunlty or 
jimior coUegas or of senior colleges that offer essociate degrees, or 
graduates of a cne-year certificate ptt ig ram u pcneo ra d fay a hoqpital or 
vocational school. 

r 34 

- 8 - 

Five states zeqiuixe that ■adlcal technologists or teciinlcians be 
licensed. Other states rtaqulxB regiiStratlGn. Althouc^ professiGnal 
association certification is vduntazy, it is ffceqmently a pra»]Liisite 
for clinical litoratory joto, anci often necessary for professional 
advamsmt. Agencies that certify personnel include the Boaxd of 
Ragistzy of the Jtnerican Society of Clinical IMhologlsts, the taerican 
Hadical VKfanologists, and the Naticnal Qertificatlon Agency for Medical 
laboratory BersGmel. 

OunDBtus CNmr ttm quality of laboratory tasting have surfaced 
recently. A naber of approa^MS to a d dr e ss ing these c cnoems vers 
suggested to the conndttee daring its public hearing. Cne approach 
p ro pos ed by sone leaders of the field is the introduction of licensure tc 
assure that labaratory pencmel have received regaisite training. Ihey 
also support efforts to define the scope of practice for each level of 
personnel. Others in the field do not believe that licensure assures 
qtiality nor do they wish to see educational credentials be the primary 
tool for differentiating oonpetencies. 

Aaoording to the American Society of Clinical Bathologists, 172,214 
technologists and 37,271 technicians were registered as of February 1987. 
Ihe BLB estinates approxiinately 239,000 jobs codsted in 1986, of %ftilch 63 
pe rcent vere in hospitals. It should be kept in mind that not all people 
doing the vork described as that of a clinical laboratory technologist or 
technician are certified. People with expertise in a scieroe field, as 
%iell as p e rsons %iithout a headth-related or eclenoe-based education, are 
hired and given on-the-job training to perfom clinical laboratory 
funtions This is particularly true in settings that are not regulated by 
the federal goverTiiient--tahyslcian office laboratories, for exanple. 

Clinical laboratory technologists and tecfmicians are most often 
voraen; only ebout 25 percent of the iNorkfcroe are men. The nore hi^y 
trained practitioners, graduates of four-year colleges, are a little older 
than the graduates of two-year colleges. Of the group of four-year 
odlege graduates, 37 percent are under 35 years old; 53 percent of the 
two-year odlege graduate group fall into that age bracket (Bureau of 
Health Profession, 1984) . 

Dental Hygienlsts 

Dental hygienlsts, working under the supervision of dentists, 
remove stains and deposits trm patients' teeth, take and develop x-ray 
flLns, qpply fluoride, and natoe iapressicns of teeth for stud^ models. 
Ihey also instruct patients in oral hygiene. In states with less 
restrictive practice acts, dental hygienlsts have e^qianded functions 
indiiding applying sealants io teeth, perfondng periodontal therapy, and 
attainisterirg local anasthesla. Host kygienists vork in private dental 
offices; other eoploynent sites include public health agencies, sdxsol 



- 9 - 

systflDB, hospitals, and businvs fizns. Htygienlsts should not be confused 
%iitfa dental assistants \iho work with the dentist, handing instzuments, 
preparing for prooedurw, and other tasks that assist in the dentist's 


In the Biddle ot the leoos, dentists f ixst began eoqfxressing interest 
in pro£tt^lK±ic oars as an adjunct to restorative dentistry. By the turn 
of the century, »ry had developed prctoools for preventative care and 
vera delivwing it to their patients. Howw, these servioes viere 
tine cn n w m i n g for tihs dentist, hmoe, costly fbr the patient. In 1910, 
the Ghio College of Ontal Surgery instituted ^ course fdr tho training of 
the **DBntal Ndrse and Assistant.*" Ihis one^yeor ptugiam graduated a 
single class before a coalition of Ghio dentists s i iDD e orted in closing it 

Three years later, a Oomecticut dentist, Er* Alfked Fanes, 
convinced his local school board to find a program to train dental 
hygienists %to %Pould iiork in the echod eysten gJ^/ing prophylactic care to 
children. Fanes envisioned dental hygienists vc rking in private dental 
ofiTices as veil, but he placed great anphasis on ^:he public schools. 

Ihe profeesion first gained legal status in Obmacticut, %ftiich 
aacnded its dental practice act in 1915 to permit hygienists to practice 
under a dentist's supervision. Ihe tolloidng year a court ruling in New 
York held that no existing Nev York law prevented dental hygienists txaa 
practicing. Subsequently, ti)e American Dental Association (ADA) endareed 
dental hygiene legislation, and, by 1951, hygienists vere lioeneed 
throu^Kut the United iStates. 

It ws not until 1947 that ADA and the American Dental Hygienists' 
Association (AHDA) developed the appr o v e d regoirements for aocanediation of 
dental hygiene programs. Them reqiiimBnts have been modified eevezal 
times; to receive ADA eqpproval today, a program most have both liberal 
arts and science ccntent, and didactic and clinical instruction. Most 
programs grant an associate degree, but often require more than two 
acadfimic years to ccnplete. A leeeer natsac take four years and culminate 
in a baccalaureate. Dental hygiene diares some of the anbivalenoe about 
education suen in the nursing profession: Oiile ftu>year programs 
undoubtedly have more academic ccntent, and presumably prepare craduates 
fbr additional career roles, there is only one level ctf dental h/giene 
licoiee. All lioeneed hygienists, regardless of the cWji mmi ttey hold, 
are permitted to perform the same range of dental services. 

Of ttm issues facing dental hygim today, autoncny is tlie most 
pressing. To titart, licensure is efiTectively in the hands of dentists, 
not dental hygienists: in all states, hygienists are licensed by a 
licensing board that is iiwiwiNeil primarily of dentists. At present, there 
is a strong m o vm en t within the praf ession to gain greater 
self-determination. Gne goal is to abbliitfi state laws requiring that 



- 10 - 

lioansad liygianists vock «xclu8iv«ly under dental wpervisicn. And In 
Oblorado, hyglenists have %fQn the riq|ht to practioe independently. Ihe 
AEA filed suit againat the state doaianding the reinstituticn of the 
reqairenmt that patients be referxBd to hygienists by licensed dentists. 
Ihe suit %ias dimlssert and the KA is currently ajppealing that decision. 

Dental hygienists are generally young vcnen. Only one percent of 
the vorkforce is sale, and cnly 10 percent is over 44 years old. In 1984 
only 13 per cen t earned wer $25,000 per year (American Dental Hyhienists' 
Asociatian, 1987). 

Dietetic Services 

According to the taerican Dietetic Association (ADA) 1972 Stixly 
OGBmission, a dietician is a "^translator of the scienoe of nutrition into 
the skill of famishing optinl nutrition to people.** Miile all 
dietitians wtmxB a consBn Interest in the scienoe of food and its effect 
on the body, th^* wdc in aary different rdes— as administrators, 
educators, researchers, and clinicians. Sob» supervise larva-smie meal 
planning at ooniianies and school cafeterias, others nnnmft hoqpitalized 
patients' nutritional needs and ixoplement qpecialized diets, %ftiile still 
others advise individuals and grcqps on sound dietary practices. 
Dieticians are also Involved in hyperaliinentation, and the clinical 
frontiers of parental and enteral nutrition. 

Ihe term dieticiM) ws first coined at the 1899 Lake Placid 
Oonference on Heme Eooncnics, but the roots of the profession extend back 
two decades sarlier to cooking schools establidied in Boston, Hav York, 
and Riiladelphia. One early practitioner, Sarah Tyson Rarer, held classes 
on nutrition for physicians and nurses before the turn of the century, and 
later edited a section of an American Medical Association (AMA) 
publication called "Oie Dietetic Gazette." 

like sany other allied health professions, dietetics mpfinrtp^ during 
World War I. In Bigland, of 2.5 ndllion sen screened for ndlitary 
service, 40% vere found to be physically unfit, most for nutritional 
reasons. Good nutrition and fbod conservation for the public, and better 
health care fdr ttm troops, especially those sick and wounded, were of 
great ocncem both in the Uhited States and Bigland. Biomedical advanoes 
during that tine also tmlped to stinulate tim fledgling profession. 

Fttam its inception in 1918, AD^ ws active in aocraditation, listing 
hoq;>itals Oiich offered reputable dietary intemehips. Sy 1927, th^ 
association had adcpted a ""Standard Cburse fbr Dieticians,** ttie first of 
several steps toward ADA-qponsored accreditation of educational programs. 
Zn 1969, the association establiiAied a registry of dietitians. To qualify 
tor registration today, m Bust have graduated ficon an accxdited college 



or univezslty, ocqplcted osrtain course and ttqperiential ooDfnnents, and 
wuat pass a national ragistration exam. In addition, dieticians oust 
fulfill contimirQ eduoation xei]LiireDBnts in order to aaintain 
certification. Ite tera "nutritionist," previously reserved for people 
%iocking in lastimili. is gaining popularity idth clinical practitioners. 
Mding the word "rutrition" to NA'b name lias been proposed, but not 
approved by the ■oriaerihip. As of the sonar of 1987, Mobers centime to 
call thnelves Miititians." 

Several iswes are currently of aajor oonoem to dieticians. First, 
tha profeesicn is aeddng to eoctend and sLw ^ U imi state licnsure. 
currently, 14 states license dieticians, and a naber of others are 
coraidering Ims. Second, since ttere is a slcv but steady trend tcward 
pdvate practice in the field, di et i c ia n s are interested in gaining 
thirdhparty reiaburaencnt fbr their servicas. FinaUy, the AD^ is 
«q;»larlng hw the field wi^ be divided into sub-fields, like several 
other allied health professions, the mm total of knowledge in the field 
has gram to the point vhare epecialization seons inevitable. Ohe nary 
dieticiara vho today consider thanselves to be qpecialists, have nost 
often beocBS so through concentration of their work in apecif ic health 
care settings. Itaos it is generally "on-'the-jcb training" rather than 
fraial education that BaJces than apecialists. At present, an ADA connitl-ee 
is develqping specialty boar^, and defining specialty areas. 

Ihe bast estinate of the size of the dietetics %mr)cf oroe cones frcn 
Ihe Anerioan Dietetic Association Uiich reported 44,570 active nadsers at 
the end of 1987. Ihe EES estimates that approodmately 40,000 dietician 
jobs eodsted in 1986 of %ihich 37 percent vers in hoepitals. 

The 1984 Study Ocnndssion on Dietetics described the "typical" ADi^ 
tteBter as a young, colleg e educated, white fasale. A little more than 63 
percent of ADA neniseni were under 40 years 61d, 99 percent have a 
bachelor's degree, 97 p ercen t are vcnen and 87 percent are white (American 
Dietetic Association, 1985) . Not audi has dianged since then, m 1986 
less than one in ten ADA menlaers was a nan. Eighty six percent of 
technician were white, ooqpared to 88 percvit of active dieticians. 
Sixty three percent of active dietician menbere were under 41 years old, 
%iiile teciviiciam were a little younger vith 71 percent under 41. Forty 
percent of active dietician aeeben have advanced degrees, and another 10 
peroant are working touard tJioee degrees. Fbr 70 percent of techniciane 
the associate degree was the hic^wst degree aamad (Bryk, 1987) . 

EBergency Medical Services 

Bnergency medical technicians (EMTe) , fOcmerly called anisulanae 
attendants, tend to people at the aoene of emergencies, and tian epor t than 
to hoepitals or other health care institutions. EKDb (basic. 


- 12 - 

intennediatft, and paiBnedic) drtenaine the nature and extent of victins' 
■Bdlcal and trBvana-related eobrgencies and prcvide limited care. 
Depending on their level of training and on state legulaticra, SOte nay 
provide such cart^ as opening and aaintaining aixways, oontroling bleeding, 
iimnhillaing fracturee', and adtaiinistering certain dzugs. 

first anijulanoe eetvioe «ibs atartad dmdng the Civil Itar in an 
effort to rtwpr e nwe aortality rates on the battlefield. Ey the late 1800s, 
several hoepitalHaased asbulanoe services were operating in urban areas 
such as Hev York City and dneimati; aeBller coniunities began 
introducing volunteer ssrvioes in the Bid-1940B. Ohe asin function of 
these early operations mm txanaport. Ihe pairecmel, oftm urticiaK and 
volunteers, wre not trained in the delivery of emergency care. 

The U.S. Dqpartaent of Haaltti, BdboatioR, and Welfare (CHEH) 
sstabliflhed an emergen^ Mdical aervioes j p iuyxam in early 1960. Ihe 
program %«s acved to the Departanent of Dnneportation (DOT) with the 
passage of the Hi^Mv Safety Act in 1966 vhich reqoixed states receiving 
federal hi^^Moy oonstruction fUnds to develop emergency services or lose 
10 percent of those funds. Ohe act reccenended that anbulanoes be 
•Ji i rrw^ with epecif ic liftaaving equipment and aenaged by at least two 
people trained in energency care. 

A 1966 report by the Netional noaeanJi Council suonarized practices 
and de fi c i en cies at verlous levels of enrxgency care, and gave specific 
zecGBBmndationB for a national effort to isprwe emergency services. The 
need foe the developnent of the BfT as an allied health professional was 
first identified in tiiis report. A conmon basic training course was the 
first step in increasing thp. professionaliem of antulance personnel. Ohe 
most iddely used training course vas developed by DCT in 1969. In 1970, a 
National Registry of EMIS (NBDCT) vas organized to unify education, 
eooninations, and certification of EMIS on a national level. 

Ih Septeeiaer 1970, under a contract fimded jointly by IHEW and DOT, 
the National Acadeny of Scienoes Subcomnittee on Aniaulanae Service 
developed guidelines for an advanced training program to train basic level 
BfF-As to become EMT-Iteanedics (EMT-Ps) . Ohis was the beginning of the 
paramedic role in the EK5 system. BCT-P's are qualified to carry out more 
advanced procedures under remote medical siqpervision, such as starting 
intravenous infusions, tracheal intubation, and defibrillation. 

BOB Oio did not fit into either of the two previously mentioned 
categories— Bore advanoad than DOVAs but not as hic^y trained as 
EMT-Pb— ware not recognised, although their nadsers increased steadily, 
in 1980, the National Registry and the DOT determined the need to poRvide 
a standardised educational program anl certification of EMIV-Zs and in 1981 
began testincr and providing certification for that category of cneroency 
amdical technicians. EMT-Is receive the basic DCT training plus portiora 
of the QfT-P GurriouliBi. 



- 13 - 

Ihe 110-hGur national basic txaininj oourae is offered by polioe, 
fira, and health departaents, and as a ncn-decuwe ooune in nedical 
schools, colleges, and univexsitias. Since 1982, paramedic training 
progms have been eligible for vbluntaxy acczeditaticn by CWEA, All 50 
states have some kind of certificaticn procedure, m 24 states, 
ragistsation with Mm Mational Registry is reqoired at aau or all levels 
of oertifiaation. Fifteen other states offer the choice of their own 
oertif ioation eoGBOPdnaticn or the National Registry eoeaiaination. All 
states leqtiixe EMiVRi to be om-tified by an eoiency of the state. 

Chreer (paid) Bfne are oftloyed by private aariaulanoe services, 
hoapitals, and wmlniral polloe and fire departnants. Vblunteer BHHb 
typically work for volunteer zescue squads and fire departunts. 

B uBitf B uu y asdical services continue to be doninated- by volunteer 
peraomel (althou^ they are beocning increasingly d^ficult to recruit) 
M» are not al%ieys able to devote tine to attaining and naintaining the 
training for advanced certification. Vblunteer BfTs are overwhelmingly 
EMT-As— basic traixMd tedmicians. Ihe nix of levels varies by locality, 
however, m rural areas, for eoonple, «tere the EMT workforoe is 
typically cr i t| i( .»w1 of voluitesrs, any DfT-Pe are likely to be volunteers, 
on the other hand, in aany urban localities, onergency nedical services 
are entirely staffed by oareer personnel. 

BQ^Bi are increasingly being used in hoqpital energency dqpartaents 
to provide energenc y nedical service and to sifplcnent nursing staff. 
DOHAs are ecnetines hired, but ^Tpically in technical roles. Nursing 
groq ps in at least two states, Remsylvania and Kamas, have fomally 
protested tiie practice of DfTe perfoming nursing fUnctlcns in energency 
departnents. Nursing leaders in Haryland have called for the develcpient 
of a job description for energency departaent BfTe. 

Medical Record Services 

Medical reoord personnel develop, isplenent, and nanage nedical 
infomation ^stens. Ihey are reeponsible for keeping track of an 
institution's patients' records, ccnpiling statistics required by federal 
and state agencies, and assisting the nedical staff in evaluating patient 
care. Zn addition, nedical reoord persomel work closely with the finance 
departnent to nonitor apending patterns. Sane nedical reoord persomel 
code infoKOBtion, arvaluate record ccnpleteness, and accuracy and enter 
infomation into oonputers. Ihree out of four jobs are located in 
hospitals; othc ^ior «ploynnit sites intilude »Ob, lunsing hemes, and 
group practices, insurance, accounting, and law fizns that ^lecialize in 
healtii natters also cnploy nedical record persomel, as do ccncanies «hich 
dsvelop and narket nedical record infomation aystcns. 



- 14 - 

Ite first B ii l oftl rmxacA adninistntor, Graoe Mhitixig Ifev^ers, was 
appoinLed by MusachusMtts Ganeral Hoapltal in 1897 to organize the 
patient care reoo r d b >Aiidh had buen aocnulating for 80 years. Other 
hospitals in the Boston area and elsewhere soGn followed suit, hiring 
Bsdical reoord pereGmel, than called '^librarians.'' Ey 1912, a gcaqp had 
organiMd to ihara infdgrsstican and ideas. Four years later, the groap 
edopted e name-^the Club of Rnord Clerks. Over the next 50 years, this 
dub evolved into a national organization, now called the American Modical 
Raoord Astociation (mgk) . 

Official standards for training p r og r ans wre not established by tiie 
itattirican Aseoriation of Nidical RKord librarians (AAMRL) , MBh'm 
pcsoursor, until 1934. Zh 1942, at the zaqpast of AAMRL, the taerican 
Nadical Association assiinerl the reepcnsibili^ of appcwixtq education 
pttjgraas for sedical record persomel. Ihe ranber of approiwl echools 
grm et e slov peoe, however. To increase tte pool of qualified persons 
in the fieJd, and provride recogniticir: to workKs idbo oculd not qualify as 
registered librarians, standards fbr programs to train a lower level 
vortar, the aedioal record technician, vara pronulgated in 1953. 

At first, sost prog ran s far both librarians and technicians vere 
hoqpitalHi)ased. But by "iht 1960s, the field's leaders vera oonvrinoed 
professional record librarians needed a farced liberal arts education. 
1970, all nfcjp i w ed pro g ra a B fbr nadioal record librarians granted a 
baccalaureate degree and vara besed in colleges end universities. 
Kograns fbr terimicians also %iara shifted^ today, technicians generally 
hold en associate degirae trm a junior college. 

As health care institutions grw .^n size, the rule of a madical 
record librarian evolved fron that of a cleric to an inf omation systens 
aanager. Ihe head of the neJica' record team often organizes a 
large-scale infbcaation service, tndns aid supervises a staff, and 
devises saans of evaluating patient care. Reflecting this ohift in 
reeponsibilities, the title of nedical reoorr^ lifanr jufi w&s changed to 
aiedical record edhninistrator in 1970. Medical jxian record p rogrr a in s 
gxdoaally have adopted oourse vork in areas such as business xnanagenent 
and data p roce ss ing. Jn - *^tion, administrators ncv nay apeciolize; 
sub-fields Include: quality assur?-*^, infornation sanagenent, 
ocnputerisntion cf infomation, am oner registry. To becoud a 
registered nedical record edtadnie'crator candidates oust have graduated 
£ran er eocxadited baooalaureate progra m and pass a registry examination. 

Becauee registration is voluntazy and medical record departmerts use 
on-the-job trained pe rsonnel tor some of the lowar^lcrvel jobs, it is hard 
to knov ttm size and ocnposition of todays medical record vorkfcroe. AMRA 
reported 8,240 registered aedioel record administrators afri 14,690 
aoczadited record technicians in 1987. Ihe BUS estimates that nearly 
40,000 technician jobs existed in 1986. WBk estimates that 98 percent of 
its flianberBhip are vonien, and epprtfidmately Ub pei\.*?nt are idhite 
(Finnegan, 1987). 



- 15 - 

Ocsqpaticnal Ihanpy 

Oo(X|»ticnal thanpists diract th»ir patimts in activities designed 
to help then leaxn tte ridlla nacMnxy to perfom daily tasks, diniidsh 
or oorzvct pattelogy, and pccnata and nlntain haalth. aherapists vork in 
mm dif f eiwit Mttings including vrtubilitative and pflychlatric 
teapitals, achodl lyitMs, nutsing hoBBS, and hoL .^th agencies, ihe 
xmtim of thaiv wdc varies aooocding to tte setting. Iterapists ifcxcking 
in Mtal bo^p^tals, tat instanoe, typically provide activities, lOaich 
telp Mtitally ill and xettaided peq^e leaxn *^ oope with daily stresses, 
as well as vnage their work and lelwire tine aoce efficiently. In 
rehabilitative hospitals, therapists vy introdooe patients to eqpiipnent, 
wtxh as vhaelchaiiv and aplints, or custan design apecial eqpiipnent; they 
mv I r changes in woric or hone enviroments to facilitate 

finctioning. BeoaiMe the field is so eactmive, therapists tmd to vatk. 
with ipecific age groups or disabilities. Ttim fi^ld can te nost reacUly 
Uvided into thoee vho work with sentally disabled people, and those ^ 
work with pivsioally disabled people. Three out of five, work with people 
with physical disabiUties; some work only with tte elderly, others 
exclusively with children. 

Tte roots of ooofiational thertqpy (CT) go back at least tMO handled 
years to Ftench physician Riilippe Pinel who found ttet nental patients 
given aanial tasks to perfom iapoNtd note qudddy than those patients 
who were idle, m tte Xftiited States, physician Benjamin Rish also 
advocated work as a tr s a tnen t fbr his nentally iU patients at 
Riiladelphia's femsylvania Hospital. In 1906, tte first training ocuree 
for coapaticnal thuapists was establiflhed in Boston. 

HOrld Her I spurred tte growth of OT, and eoqpanded its scope of 
practice to include physical as well as nental rehabilitation. Initially, 
four ai xecoratruction aides ware recruited for service in European-based 
Jtanerican any hoapitals. And in 1917, it was decided ttet 200 otters were 
needed to "furnish f&ms of ocapatiois to convalescents in long illnesses 
and to give tte potiwits tte therapeutic benefit of activity." Ihree 
czadi pzosraDB were established which trained hundreds of OI aides by 

Ote National Society for tte Rxnotion of Oocqpational Ihere^ vms 
established in 1917; three years later tte association changed its nana to 
ttet in uee today, tte Jtanerican OccipRtional Therapy Association (Mm) . 
In 1923, tte field reoeived a anjor boost when tte Federal industrial 
Rehabilitation Act regoired that every general hoepital treating victias 
of indLMtrial accidents provide occupatiaial therapy. Alao that year, 
jl023^ first ostPlt^iBhBd standards for training programs: these 

a pre f ^'ssional training laugra a of U-nonth duration open to 
hidi school graduates. Ten years later, MSIk and tte American Medical 
Association began collaborating an accreditation for OT programs. 



- 16 - 

SinoB then, the field's bod/ of knowledgre has expwnded cxnsideirably, 
and eduoaticnal reqiidraBents have been stnngthenBd. Today there are two 
levels of educaticn-^technical and professicanal, and there is no upwsund 
acbility through eoqperienoe alone. Bkication mujiaas are aocxedited by 
the Oomnittee fbr Allied Haaltli Bdkicaticn and Aocxeditation, an am of the 
Anerican Madical Aaaociaticn. Vachnicel educeticn laujiaius grant an 
associate degree and pnpaxB individuals to beoone cxedentialed as an 
oooqpa t io n al therapy assistant (GOflA) . Amfeesional pimiaius are offered 
at three levels, baooalaureabe, "xstHbaooalaureate certificate, and 
■aster's degree. All pcepere a person to beoone cxedentialed as an 
oooqpBtional therapist (OIK) . Ih addition, oocqpational therapists now 
^>e c ialia e in one of several sufefields: gerontology, developnental 
disabilities, training in activities of daily living, prosthetics training 
and oonstruction of eplints, and the rehabilitation of people with apinal 
coed injuries and neurologicBl disocders. 

As of 1987, 34 states plus the DLetrict of Oolucbia and Rierto Rico, 
have or licensure laws. All laws qpecify that the A0IA certification exam 
be used as the licensing eacBin. licensure also requires a degree or 
certificate from an accredited educational progr a m. 

Though the roots of oocqpational and physical therapy are similar, 
occupational therapists' autononiy has been slower to develop than physical 
therapists'. Hiile reiabureement for GT inpatient services is covered by 
third-party payers, raiabureanent for outpatient and in-hcne services, 
until recent changes in Medicare, has been more erratic. Still, a growing 
nwber of therapists are in private practice. Some work in coraulting 
firms, or nultiso'''cialty group practices, %idle others are solo 
practitionere. 'typically, patients are referred to then by physiciai^ or 
other health professionals. 

To leaden in the field, a aajcr concern continues to be OT's 
difficulty in meeting daoiand for qualified practitioners. Oenanl has 
grown considerably weac the past several decades, but leaders alsu 
attribute the shortage of practitionere to the field's failure to attract 
sufficient nunbere of ivtudents. Ifeury people's unwillingness to make their 
careere in psychiatric settings say be iapeding recruitment. Also, legmen 
often confuse OT and FT, and the more visible and autcncnous IT may be 
mora attnctive to potential students. 

The best estimate of the si/e of Xi» ocrapational theonqpy workfaroe 
is the American Oocupatioml Therapy Association's list of registered 
active menisere, lAiich nBi>ared 27,300 at the end of 1987. Ocoiiational 
therapists are most often wcssn (95 percent) with a median age of 32. 
Most work full tiar (70 percent) and 20 percent are self-cBployed. ihe 12 
percent who have masten' degrees have exrweded the minimum educational 
requirenent. Ihe aean income reported in 1986 was approdiiBtely $26,500 
(AOEA, 1986). 



- 17 - 

Xh 1986 the MJDi cxunted 7,909 o^K-ified Ooaqpatlcnal Iher^ 
Assistants (OGOAs) amongst its nenberBhip. Iheir characteristics were in 
wne ways siirilar to the ttmapists. Iheir age and proportiGn that were 
%aaen and waricad fiill tins were alinost identical to thenqpists. However, 
tive eduoaticn and wxningp dif teed. Seventy-four percent had associate 
degrees, 29 percent had diploDoas or certificates, and their average 
earnings was $16,182 (AOA, 1986). 

Ehysical Qienpy 

Riysical therapists plan and administer treatDont to relieve pain, 
laprcve fkmctional nobility, aaintain cardiopulnonary Amction, and liiait 
the disability of peqple suffering tsm a disabling injury or disease. 
Therapsutios include: ewrcises for inproving enluranoe, strength, 
ooordinBtion and rrnge of notion; electrical stimilation to activate 
paralyzed mttcles; in s tru c t ion in the xiae of assistive devices such as 
crutches, or cairm; and and electrothenqpy to alleviate pain and 

proBOta healing in soft tissues. 

Rxysioal therEqpists woric in a variety of cnplc^ment settings. In 
1986, hoepitals prwided one-tihizd of jobs. Other najor aqployexB axe 
rahabilitaticn facilities, home health agenda, and mrsing hones, WDg, 
ectool eystevs, and clinics. In addition, alnost- 20 percent of therapists 
are in private practice. Scne private practitionfedns work solo or with a 
group practice; others provide an instituticn. such as hospital or nursing 
hone, with can on a c o ntra ct basis. 

MDdkuni physical therapy was brm during Morld War I when the country 
was suddenly t&oed with a need to rdiabilitste large nabera of i^ounded 
soldiera. In 1917, the Surgeon General of the Any initiated an 
interaiva, ahort-^tem program which trained 800 "raconstniction aides,** 
ell women, in physical therapy. Reconstruction aides %ffere civilian 
nxpl^yees of the U.S. Azay Medical Oorps and typically worked in any 
hoq^itali^. As soldiera ware discharged after the war, the need for 
recomtzuction aides grw in the civilian sector. In addition, the any 
continued to eni>loy aides to work with hoqpitalizec^ veterans. 

In 1920, the Anericen NQner:> ihysical Iherapeutic Association was 
fbnaed by reconstruction aides «ho had served in the war. Recon str uction 
aides were considered charter ncbera. Others seddng to joir^ the 
association were required to have graduated ftOBH '^raoognized ecfaools of 
i^MJiy and therapeutic exerciee with scne knowledge at either 
electrotherapy or hydrotherap!ir'.** By the end of 1921, the new association 
had 245 naonbera. ^ihis a8socia\*ion becane the current Aanerican Riysical 
Iherapy Association. 


^ 44 

- 18 

liarld Nar II taraug^ a sudden incxBase in the demand for then^ists 
to trMt IxijurBd servioeBien; a demand met largely throug|h rapid 
MUblldnent of federally funded, aooelerated ptuyiam to pnpazB oollegfe 
graduates trm fields euch as phyBical edticaticn fbr practioe as 
therapists. Often qperated in parallel %dth existijfig four^year university 
dagpree or certificate programs, these aooelerated progra m s vere 
disocntlimied at the end of the var. However, the vry graduates they 
sifplied %iere generally regeorded as hi^y caqpetent, and this tenporary 
cfystSD provided iBprassive evidenoe of the ability of educational pro gi - ams 
to reqpcnd to a sudden change in maiixMer demand. During the 1940s and 
early 1950s a series ot eevere poliaDyelitis epidemics cxeated another 
rapid rise in demand tac therapists. This time both donand and supply 
%iera strongly influenced by the private eector. Itassive donations to the 
Kational Foundation for Ihfantile Itaalysis (Kerch of Dines) vera used to 
enploy therapists, set up treatment centers, and subsidise thereby • ^ 
large nnber of peticnts. Oonourrently the Fbundation invested heavily in 
education of therapists by: 

o underwriting salaries for mary nev faculty positions to 

o existing echobls to eoqpand enrollments 

o funding an intensive student recxuitaent and scholarship 
p rogr a m that drw many nev people into the field 

o stqpporting developsent of graduate p rograms for faculty 

Ihe dramatic reduction in ninber of nev polio patients following 
developnent of the SalJc and Sabin vaccines j~ the early 1950s had only a 
brief effect on the demfeuvl for physical therapists. Growing interest in 
the vocational r&.iabilitation of young adults and the e>qpansion of 
rehabilitation services to previously underserved groips of patients with 
a %dde variety of ao v caDen t disorders soon absorbed the maipcwer previously 
needed for care of acute polio patients. 

Today, all states reguire practicing physical therapists be 
licensed; and aiplicants oust hold a degree trm an AFIA-acczedited 
ptoyiam prior to taking the licensing exam. Since 1960, there have been 
three educational avenues to entry-level jobs as physical thenqpists: 
baccalaureate programs, certificate piujiams for people «ho already hold a 
bachelor's degroe in another field, and tuo^yaar master's programs. In 
1979, the »PIK announced intentions to elevate the entry^levei regairenent 
to a BBister's d oji m a mandate that encountered vigorous opposition, 
especially fran the Anarican Hospital Association, deans of allied health 
programs, and certain hi^^ education associations. As a result, the 
mandate has been softened to encourage a general n wnmait toward the 
master's degree. 



19 - 

in 1967, an assistant-level positicn was czBatad so that physical 
thsrapists oculd delogate noce routine tasks, and traat greater 
nuuben of patlmts. At present, tiiere are approodinat^y 17,000 
practicingr physical tharapy assistants. 

Riysioal therapists have woacm autonony than sost allied health 
panctiticnare. Many are in private practioe and the APIA directly 
aocxedits educational pixxgLBm indtafmdant of CMIEA. Scne states allow 
patimts direct acoass to physical therapy services, %iiich eases entzy 
into independent practice for tiianpists. niirty^dc^ states nw p»mit 
Urn thfirepist to evaluate patients without aadical referral; 11 of these 
also peradt UealJ M nL oC patients so evaluated. Lagislaticn an direct 
access is pending in about a doeen other states. 

As the sccpe of practice in physical therapy eoqpanded to include 
eervices as diverse as pulaonary therapy for critically ill patients in 
intensive care units, developmental aflPciBBWont of hig|h risk neMbom 
infants, home care for elderly strcAe and arthritis patients, and 
industrial consulting to reduce low bade injuries, apecialization has 
beoGoe a feature of the careen of sany therapists. In 1978 the American 
Riysioal Therapy Association established a Board for Certification of 
Advanced Clinical Conpetence vhich currently oversees the examination and 
certification of clinloal epecialists by Specialty Boards in six fields: 
caxdiopuljncnary, clinical electrophysiology, neurological, orthopaedic, 
pediatric, and wpaacts physical therapy. Siirty univeraities nov offer 
post-professional graduate p i tugia i is for advanced professional study by 
eocperienced tiierapists. Ihis included nine doctoral level programs. 

AFEA estioates tiiat the nnber of licensed ph^'sical thereqpisti* in 
1986 tu ilave been does to 66,000. Rxysical therapists are most often 
vonen, %dth soa constituting 25.4 percent o£ the w t kf aroe in 1987, a 
little down trm 28.8 percent in 1978. Wcnen therapists are on average a 
little younger than sen (35 yeare old versus 38) • Ihe proportion of 
minority therapists mained between 4 and 5 pei tae nt in the past decade. 
Ihe 15 percent of the i rf ork f arce idho %iorked full time fbr thenselves vere 
the hi^^est eamen, grossing nearly $73,000 on average in 1986 conpared 
%dth approKimately $32,000 for the 67 per cen t %iho %9ere fUU-time salaried 
enployees. Ihe educational attaiments of physical therapists have 
increased during the past ten yeare. Ihe percentage with vastere' dagrees 
has increaaed fron 15.2 percent to 21.5 pocent since 1978, and the 
percent a ge vith a dxtoral degree increased sli^^xtly fkon 1.1 percent to 
1«4 percent (APIA, 1987) • 


- 20 - 

Radiologic Tachnology 

Radidlogic wrvioas tegan with the diagnostic use of x-rays and the 
applications aC thsM and other types of ionizing radiation for 
therapeutic purposes. Originally prcvided aLnost eocdusively by 
radiologists (physicians) and their technical assistants or x-ray 
technicians (nov called radiographers) , radiologic senrices have oqpa n d e d 
ocmidiR^v in raoent dsoadas. Km professions have em mt ied %dth wriiral 
and technologioal advanoes. Han applications of radic»ctive tracers led 
to the hirtii of r^^ear SKlicine technology; the l^nventicn of theraqpeutic 
x-ray equipssnt for treating canoer resulted in the field of radiation 
ttmap^ technology; and the developnant aC ultrasound imaging systens have 
created a new category of radiblog^ pencnnel, the diagnostic wdioil 
SOI txjr&[i WIT • 

Radiologic technologists and technicians (including radiographers, 
radiation tiierapy technologists, naclear aadicine technologists and 
diagnostic ■adioal sonographers) held about 125,000 jobs in 1986. About 
tMo of every three jobs vera located in hoapitals. Otner aqploynent sites 
indixle dkiics, laboratories, and doctocB' ctfficas. 

Ttaenty-f ive years after the discovery aC x-rays in 1895 by Wilheln 
Roentgen, 13 x-ny technicians gathered in Chicago and fanaad the American 
Association of Radiological Technicians (nov called the Amsrican Society 
of Radiologic Technologists) • In 1920, a ocnnittee of physicians vas 
appointed the Radiological Society of North America to consider 
standards far the training of x-ray technicians. l\io years later the 
American Registry of X-ny Technicians (nov called the American Registry 
:'f Radiologic Technologists) vas organized by the Radiological Society of 
Horth America and the American Roentgen Ray Society. Ihe registry %ias 
controlled by physicians until 1961 \ihen the conposition of the registry 
board was charged to include technologists, initially, all training in 
radiologic technology %ias done on the job. Gradually, however, hospitals 
organized echobls for technicians, and a p r o g ram CTirrnnf^fl of a year of 
classMork followed by a year of clinical training evolved. In 1933, the 
first three piujiam %pere recognized by the registry. Today, CAHEA 
accredits more than 1,000 formal training prograns. 

Radiolcgic technology education changed after World Har n, partly 
as a result of the 6.1. Bill. large lunbere of retuminj veterans vere 
interested in careers in the eaqpendlng health care field, and, at the same 
time, wished to pursue formal education under the 6.1. Bill. Many 
two-YMr college aAninistratoons, recognizing this nsw market, established 
two-year radiologic technc>logy pimiaw ?i<iich granted an associate 
degree. This development came on the heeju? aC a growing m o v e ment within 
the field to extend the duration of training programs. 

At present, there are formal training piugiaius in radiography, 
sonography, radiation therapy technology, and nuclear aedicine 
technology. They range fkom one to fcjr years and grant a oertificatef an 




associate degree, car a baccalaureate. l\iD-year p cogr ams eure the most 
amai. Scne one-year pioyiaiuB attract health care professionals %to are 
interasted in dianging fields— nost often, respiratccy then^iscs, 
registjred nurses, and aa di c al tedmologists. Oertificate prog taim also 
at tract radiognphers «ho want to ^wrlnUze in ultrasounl, radiation 
thexapf, or niclear Bedicine. At present, four^aar p r ogiaa s are designed 
prinurily for people Interasted in teaching or aqpervisocy positiora. 

Ihere aipearB to be a trand towanl piuyiam of longer duration based 
in institutions of hig^ education. Because sone aducatocs feel that 
advanoas in technology hove oade it difficult to adequately train stidents 
in tMD years, a nater of associate dagree pimiaas are aj^erlBcnting with 
a third year. Sooe leaders in the field feel that the slight difference 
betMaen a tixree-year asso c ia t e degree prcjraB and a four-year bachelor's 
program will push the field touard naking the baccalaureate degree the 
educational standard for antry^level jobs. 

As of nianer 1987, only five sta t e s- Wo w York, New Jersey, norida, 
Odifomia, and Kentucl^^-had licensure laws for radiologic 
technologists, in 1984, Oongress passed the Jennings Randolph Bill which 
requires that states either establish ninioal educational standards for 
radiologic technologists, or adopt extant federal requircnents, which call 
for v oluntary oonpliance. Alnost all states have opted for volui.^iy 

Ihe radiologic technology worlcfaroe is one of the largest among 
the allied health fields. Die Bureau of Health Kofessiom estimates that 
143,000 radiologic health service warkers e)eisted in 1986 — of which 
approodmately tMo-thirds were wcnen and half were under 30 years old. 

Respiratory Tlierapy 

Raspiratary therapists provide a range of services: fron csexgency 
care for stroke, drowning, heart failure, and ahocik, to providing 
tenporary relief to patients with cnphysaa or astfana. Ihey often treat 
patients who have undergone surgery, because anesthesia drrirnrnrn 
breathing and respiratory therapy may be pcescribed to prevent the 
developnent of reepiratory Illnesses, me aajority of reepiratocy 
thenq;>ists wock in hospital settings, althcug(h incxeasing nadaezB are 
•nployad by nursing facilities and bene health agencies. 

Since the 1800s, doct ors have pieeciibwd oo(ygen thenqpy for 
individuals tdth cardiopulmonary problens, and until recaitly the task of 
actually adninistaaring tiea Umiit fell to attending nurees. Arter Nbrld 
itor n, hoMBver, auch of the equipment fbr adhninistering oor/gen became so 
eop h istioated einS aaqpcnslve that ackdnistrators began assigning 
vaaplratcay care tasks to orderlias who baoane known as oocygen onSerlles. 


^< 48 

- 22 - 

Ihese first respiratory thenqplsts, althouglh usually oqplcyaes of nursing 
departnents, fre(]Liafitly develqped d jrBct relaticndxips with physicians, 
and often came to know macB about gas therapy than their tmwrHate 

Ihe field's first professional organization, the Inhalaticnal 
Itexapy Association was faned in Chicago in 1946. Mew, several decades 
later, tht ocganization is national in scope anl is called the American 
Association fdr Bsspiratary Oare (AARC) • 

As the field and its bod/ of sedical knowledge evolved, the ranges of 
tadoB^ perf ooBd by xespirstory therapists widened to include both the 
flundane and the hig^y ocn|>leK. As a result, in the late 1960s leaders in 
the field pranoted the idea of developing an entry^level position so that 
respiratory therapists oculd be relief of ttm mxB routine tasks. In 
1969, the first inhalation therapy technicians certified. 

Training is of fend at the post-secondary level in odleges and 
\miversities, sedical schools, trade schools, and hoepitals. In order to 
be accredited by CAHEA* piuyiaius for reepiratory there^ists sust be of at 
least two years duration and lead to an associate or baccalaureate 
degree. Technician pr og r an s xisually last one year. Oertificaticn is 
voluntary and available throug^h the national Board for Raqpiratory Care. 
As of JWie, 1987, xespiratoty care pL^rscmel were licensed in 18 states, 
and licensure bills had been introduced lii 10 others. 

At the prosent tine, mters of the field are oonoemed about issues 
relating to conpetition with other health care workers. Ihey are alanoed 
by the incursions into the field by other health care workers, especially 
nurses, vho in the early years perfcnoed the functions (or the precursors 
of the functions) usually handled by respiratory therapists today. To 
halt these incursions and protect the quality of reepiratory services, 
therapists are seeking lioaraure in all 50 states. It should be nested 
that the AARC, unliJoe nany other allied hmlth organizations, is not 
currently strivinc; to achieve greater independence trm physicians for 
itsneribertfi^. The leader^' of the AAKC anticipates that raqplratory 
personnel will oontime to woodc under the direction of physiciuis. 

The Bureau ot Labor Statistics estimates that over 56,000 
respiratory therapy joias existed in 1986, the majori^ of then in 
hospitals. AARC suggests that adhninistrative positions lune excluded in 
the BL5 count. TMo-thirds of respiratory therapists are under 30 years of 
age, and, unisual for an allied health field aLnost 40 percent are men. 

Speech language Bathology and Audiblogy Services 

Audiblogists and qpeech-language pathologists held approodimtely 
45,000 jobs in 1986. JUst over half of these positions were in elementary 
and secondary schools, universities, and colleges. Hoqpitals, nu»ing 




hcuBS, qpeedi-language and hearing centers, and porivate phyBiciars provide 
Bost the the renaining jobs. Uilite aost other aUied health profosicns, 
the ipeech-lanj ifyyi h e ar ing profession does not function exclteively or 
even principally in the Bedical varld. Mocsover, the care provided by 
ttmsB professionals was not prsvioualy eqpplied by physicians. Oie 
dsvalopnnt of these fields took place in the educational sector. Early 
in this ontuiy, sdaoatats bsosBM inbsrsstad in introducing ipeech 
correction services into the pidalic schools. Ihe Odoago school systan 
IMS first, hiring 10 qieech oorxsctisn taadMzs in 1910. within 6 years, 
Detroit, Boston, New York, and San Itancisoo had folloMBd Chicago's lead 
and also «B|>loyed epeech oorractionists. adversity education of perBora 
interestsd in MpmA correction vas initiated in the Uiited States around 
1915 at the Iftiivarslty of Wisoorain. 

Most early speech oorrectionists saw thaneelves as apecialized 
teachers of elocution and belonged to a large organization known as the 
national Aaaociation of Teachers of Speech (MKTS) . Tn 1925, a group of 
qpeech corrs^^donists decided that faming a sani'-flutoncnaus organization 
under the mM^> i o es of mis would best serve their professional interests 
and the taerican Aoadeiv of Sprach Gbrrection (MVSC) vas bom. Among the 
goals of the fledgling organization was raising "existing stardards of 
practice among WDrioers in the field of apeech correction,'* end eecuring 
■^public recognition of the practice of qpeech correction as an organized 
profession. * 

During the neoet several years, the aseociation grew, and along with 
it, dissatisfaction over its close ccnnecticn with MKTS. Ihe traditional 
tixae of the annual NKTS meeting apparenUy was not convenient for many 
AASC BBdaers, and many felt that AASC should be affiliated with groups in 
the medical irarld instaad of NKES. After 25 years, oonplete separation 
trm NATS was achieved; today the organization is known as the American 
S|>eech-Ianguage-«earing Association (ASHA) . 

A BBSter degree in qpeech-language pathology or audiology is the 
basic credential in this profession, although there are mnerous prog iaim 
in oonBunications sciences and disorders at the baocalaureata level. Of 
the apprcadnately 235 odUeges and imiversities offering aastsr degree or 
doctoral pcogiaMs in speech-language pathology and audiology, about 
tMo-'thizds are accredited by ASHA. ooursawork at accredited schools 
includes basic oimiinicBtion processes, study of apeech-languagepathoiogy 
anVcr hearing disorders, and related areas such as the psychdogical 
aqpects of ocBnunioation. Most perscns with a master degree acquire tiie 
Oertif ioats of Clinical Oonpetence (OOC) in either speech-language 
pathology or in audiology offered by ASHA. To earn the OTC, the 
individual must haHA a master dsgree or its egtiivalent, oonplete a 
sqpervisrd cJ in ioal felloMship year, and pass ASHA's written eacam. 

Thirty-six states require that people offering epeech-language 
pathology and audiology services hold licenees if they practice privately 
in clinics, or other •vn-school settings. Medicare, Medicaid, and other 

er|c 50 

- 24 - 

tiiirdhparty pay«n pc^ far ths aarviow of licensed prac±itlone!r8. m 
states do not Im lioensurB lows, tfadicare and Medicaid reqLiize that 
qpeech-language pathologists and audiologists neet the aducaticnal and 
clinical eoqperianoe reqaizesMits for ttm OOC or be in the prooess of 
aosunuloting the naoessaxy clinical eoqparienoe. 

mcrabsing nwbm of individuals within the field an engaging in 
inlepenlent private practioes. Ohis tra^d, lAiile fairly nev, is rapidly 
growing. like leaders of other increasingly autcRanous allied health 
professicra, authoritias in qpaech-lanTiage pathology and audiology are 
seeking to ensure that standards of practioe ranain hi^. 

ASH\ estiaates that approodaately 86,700 ^jeach^languarje 
pathologists and audidogists are active in the warkforoe (SheMui, 1988) . 
Apprcodaately fifteen p ete * i t of pcBCtiticners certified by ASH^ are 
oudiologists and aost the the minder are qpeechrlanguage pathologists; 
idaout 2 percent of qpeech-language-hearing practitioners are certified in 
both epeech-language patholcgy and audicdogy (AESA, 19&8) . In 1987 
audiologists earned sli^jhtly aore tiian apoech-language pathologists. ASHA 
imber audiologists' aadian annual salary in 1987 was $28,000 ocnpared 
with $25,000 for qpeech-language pathdogists (Guthrie, 1988) . UtiB 
apoech language pathology w or kf orce is overuhelningly white and f enale 
(iqpprGodnately 95 and 89 percent respectively in 1988) . 

New Allied Health Fields 

Ihe ccBBiittee recognizes that the 10 fields selected for this study 
represent establiahed, traditional allied health professions. Ihe 
changing pattern of health care delivery has tended to apaun new allied 
health fields— fields that nay develop as changes in the health care 
system take plact' erd as tectoblogy changes or eagands. Ihe oonndtteee 
locked briefly at tuo fields that have recently cone to be recognized as 
allied health ocofiaticns— perfusion and cardicwascular technolcgy^-to see 
if developing fields tend to follow the same genaral pathways of the 
establiidhed occupations. These two fields developed from a core they once 
shared with reqpiratory therapy. Early school ymgia m s covered heart and 
Itmg procedures; as technologies developed, practitioners qpeclalized in 
one or another araa and separate fields and occqpations evolved. 


Ferftisionists started out in the nld-1950s as puop technicians for 
heart-lung nachines— eguipnent devised to withdraw blood frcn a patient's 
bod/, dearae and ooeygarate the blood and punp it back into the body, 
lhaee technicians noved with the eguipnant from the aoqwrinental 
laboratarlas into clinical settings as assistants to surgeons and 
anethesiblogists. irainaee were often drawn frcn other disciplines. 
Including nursing and reqpiratory therapy, and %«re trained on the job 
until the aid 1970s. 



By the Biid-1960B, perAsionists saw the need to devslop a system for 
certifying prectitionen and to eBtabllsh a alniacd baae of knowledge for 
the profteBioi^nMy fiognad the Anerlcan Society of Bctra-Gorporeal 
Vechnology (haBECT) to ccganize the Ffrofessicn and to prcndde Inf onatlcn 
and profewicnal ae^zvioea to its asnbezB, and in 1968 KaSECI began a 
progzam of certifioation for perAisicnists. Ihe taerioan Board of 
GBzdiovaaoular Perftiaion ws establiihed in 1974 to oonlkact certif icaticn 
as an independen t activity, in 1977, CMflEA zeoognized peorftisicn as an 
allied health pcofessicn and the %ny was peeved tac astabliehlng acxzedited 
schools for training. 

Any of the technicians trained on the job prior to the 
eetablitfieBent of aocredited training piugiaim were able to sit fbr the 
certifioation tm, but since 1981 (uhen schools beoau available) no one 
■ay sit for the SNsm idthout having graduated fixn an aocxedited program. 

FerfUsionists work xander the general sifjervlsion of a physician. 
Iteraas they once inrioed only with heart-lung uchines, perA»ionists nov 
■anage hi^y technical paUent aanitaring devices in the operating roon. 
Ihey are no longer limited to heart bypass procedures but now also assist 
during organ transplant procedures, ihe profession is striving to eamand 
its aoqpertise and not linit its focus to one technology. It is eo^anding 
its scope to include nanaging patient monitoring devices that have not 
been dainad by another aUied health field. Perfusion is taking a course 
not dissimilar to those of dder, well-establiahed allied health 

cazdiovaacular Technology 

The field of cardiovascular technology ooncems the diagnoels and 
treatment of patients with cardiac and peripheral vascular dinnnnr and is 
segmanted into three distinct areas: invasive cartdiology, noninvasive 
cardiology, and ncninvasive peripheral vascular study. As each of the 
areas develqped and as changing technolcgy led to their divergence, 
technicians were trained in each uea to ctnduct the requisite test and 
procedures. Ohe three groups havu ranained together for the purpose of 
designing an education program. Since r>»r— 2981, cardiovascular 
technology has been recognized by GAHEA as an allied health profession, 
cardiovascular technologists and technicians T[«»''f»Hrft in one or moce of 
the three areas. Ingram accreditation criteria have bean developed, but 
thus far there are no accredited piuyiaas for training cardiovascular 
technicians. Several ptugiai B S are eaqpected to be available by fidl 1988. 

The range of skills and training is broad. Within the area of 
noninvasive cardi o logy, for escanple, procedures range fkon 
electrocardiography (BOS), which may be taug^ in a few hours, to 
echocardiognqphy, an ultrasound technique «hlch reqaixes zelatively 

• 26 - 

ttcbensive training. BQ5 tachnicianB an often cxoss-^trainad en the job in 
eaoercifie testing a n ot her non-invasive caxdiology procedure. 

Ihe anociations ziinsenting Gaardiovaacular tachniciane vho do EHBs 
and eooerciaa taats have mteULhimd a aqparata board to test technicians 
%te> vant to be cx a d e nti alady the njority are not cxadsntialed. 
Ihstitutlcus cnoouragye canedentialing, but do not require it. Ohese 
technicians are alloyed in a variety of setting^ including physicians' 
offices, out-pationt clinics and exiercise dinics. Ihey under the 
siiwrvisiGn of nirsing staff or i^tysicians. 

Urn technicians that apecialige in ecfaooardiograins are often trained 
on ttm job. Only six of the 30 schools offering ultrasound training 
indude training in echooardiograpfay, and none are accredited under 
OHEIk's nsv eesenMals fSor oerdiovaacular technology. Ttaining in these 
pa^ugiams mist gmarally be sifplenented by cn-tfae-job training, but not 
all health oare facilities have the capability to train the 
echocardiography technicians they need. Ihe densmd for these technicians 
is hig|h and their salaries are rising. Ihey are often drawn fcan other 
disciplines, including nursing, physical therapy, and re^iratory therapy; 
toa trainees are without a BBdical badoground. 

The Society of Diagnostic Nadical So'cgr ap hers represents 
echocardlographers and other scnognqphers. Ihere are two boards whldi 
pcovide testing for oartif icatlon in the field. Generally, individuals 
need to have several years experience before qoalifying to ta)ce the exam. 
Ohe aajority of echocardiogn^ahers are not board certified, but interest 
in otttif icatlon is growing nore so than in any of the other 
car .^vascular technology areas. Ihe American College of cardiologists is 
encouraging certification throu^ only one bod/, which will probably 
pcovide increased impetus for certification. 

Althoug(h echocardlographers have sona degree of autonoBS/, they work 
closely with the physician. Echocardiography overlaps with radiologic 
technology, which includes ultrasound technology or sonogreqphy. A 
acvement to draft state legislation ragalring that ultrasound operators be 
radiology technicians is being f ou;|ht by non-radiology technicians who 
woric with ultrasound technology. 

Invasive cardiovascular technologists assist physicians in, as their 
title suggests, invasive heart procedures. With the developnent of bypass 
surgery the nater of catheter labs rose md demand for technologists 
grew. Developnents in baloon angioplasty and laser technology nay have 
the sane effect. Kectltioners are generally drawn from oth^ clinia^l 
areas, including sc-ray technology and mrsing, and are typically trained 
on the job. 

Honinvasive peripheral vascular technologists assists in diagnostic 
studies of the the peripheral circulatory systan. As in the case of 
echocardlogre^iy, ultrasound techniques are used in the diagnostic studies 



- 27 - 

and substantial training is regaixod, and lite ectecardiogreqpherB, 
noninvasive periiiiaral vascular technologists vho cxnduct ultrasound tests 
face ooqpetition trcm radiologic technologists. Bc]u^pnent flanufacturers 
hove been the prixDary eouxoa of training; th^ have estcd^liahed educaticn 
piogxa n s in tteir own fteilities as veil as prcvide cn-^site, in-senrioe 
training. In the early days, aost trainees imne nines, but the field nov 
draws p e irsons fkon other disciplines. 


Allied health practitioners are enomcusly diverse in terns of the 
%»ric th^ do, the amount of education required, the types of institutiors 
that offer the educaticn, and the regulatory gcn^^ of their activities. 
However, their evolution fbUowed courses that ere ccmDon to eeveral if 
not all fields, lha fields developed to neet identified health care 
naeds, often taking over tasks that physicians no longer wanted to 
undertake. Initially on the job training was the nom, but eocn the 
practitioners fionned an organization, defined their roles and identified 
einliBim qualifications that pracdtioners nist possess. 

certification of practitioners and acczeditation of eduoaticn 
piujiaius followed, tbrtf allied health fields today use the Oonnittee cn 
Allied Health Education Aocxeditation (an am of the American Hddical 
Association) to accredit their prognoDs. 

Others have preferred to keep acczeditatdon within the purview of 
the field. Many gzwqps view this as one of the key attributes of a 
profession. Alnost inevitably the educational requireDBnts have incaneased 
and often licensure followed, lAiich eerves several purposes including 
protection of practitioner's educational investment. Often tensions 
developed between the practitioner's field and the nedical or dental 
speciality fron which the field developed. Hew professions have sou^ to 
control their own destinies. Ohe originating professions have SGmetimes 
been reluctant to relingoish control. Ohey fear conpetition trm the very 
groqps they ini^^Ally encouraged in order to relieve thoooselves of 
unwanted tiutf 

Seme allied haal^ fields, such as physical therapy nade the 
transition txam hospital training to baccalaureate education in 
universities end oollegBS in the first half of the century. With the 
oooBunity obllege swm e nt in thB 1960's, a distant-level piugiaum 
developed to neet the growing dnanS fdr eervioee end the need to sake 
practitioners sore productive. For other fields, the transition to 
ecadmia was nade such sore slowly. Radiography and reqpiratory ther^sy 
are in ttm sidst of evolving toward the baccalaureate degree, so that now 
we eee ecne one year piugiaas giving way, priaarily to two year and 
baccalaureate prograns. Those with hi^ier Jiijieee tend to gravitate 
toward adhninistrative roles. 

Ihe spectrin of allxed health today includes fields at different 
stages of evolution. Ihis report npreeents a snapAot of then at one 
point in tiine. 


• 28 • 

Merican Dietetic Association. 1985. A Hev Look at the Itofess5(jn of 
Dietetics: Report of the 1984 Study GGmnissiGn en Dietetics. 
Oiicsgo: Anerican Dietetic Associaticn. 

Anerioin Dietetic Association. 1972. The Rrofession of Dietetics: Report 
of the Stud/ Oconission on Dietetics. Chicago: American Dietetic 

Annrican Journal of Dental Science. If ^^tOFisl: Dental Hygiene. 
Vbl. 5()»inii):244. 

toe . ri Medical Aasooiation. 3987. Allied Health Bducation Directory - 
1987, Chicago: Anerioen Medical AssodLatiGn. 

Ameriain Ooopational aherapy Association. 1986. 1986 Menter Data Survey. 
Rodcville, m. : Anerican Cca^ational Thsrapif Association. 

American Ri/eical Iherapy Association. 1987. K37 Active MEsoberBhip 
I%t>file Survey. Alexandra Vie. ^ American Physical Ihere^ 

American Rrraical Oherapy Association, ca. 1980. A Decision for Change. 
Alexandria, Va. : Ihe Association, undated. 

American Hiysical Iherapy Association. 1979. **Ihe Beginnings of 

'Modem' Riysiothenqpy.** Ihe Beginnings: Physical Ohera^ and the 
AFEA. Nashington: American Riysical Hheapf Asssor^ation. 

American Society of Clinical Pathologists. 1987. Board of Registry. 
March. Newsletter. 

American Society for Nadical Technology, ca. \980. Mission Statement. 
Uhdated wall plaque. 

American ^peech-Language-Hearir^ Associaticn 1986. Obnibus Survey !nnends. 
1982-1985. Research Division. Rodcville, Md.: American-Speech- 
language-Hearing Association. 

Biglcu% L. A. 1982. Medical Reoords Bducation: An Historical Pexspix^ve. 
Journal of American Medical Rroords Association. August. 

Bryk, J. A. 1987. Report on the 1986 Census of The American Dietetic 

Associfition. Jcumal of the American Dietetic i^sociation. Vbl. 87, 
No. 8 (August): 1080-1085. 

Burton, G. G., and Hodgpdn, J. E. 1984. Respiratory care. Second Edition. 
Riilrtelrhia: J. B. Lippinoott. 

ODltey, R. We 1978. Sinrvey of Medical Technology, Chapter Ixxd^, 
Md.: C. V. Mjsby. 



- 29 - 

Cdrbett, F. R. 1985. A VeK Look at the Kofession of Dietetics: Report 
of the 1984 Stud/ oaanission cn Dietetics. Aoerican Dietetic 

Ckitbett, F. R. 1909. Ohe Training of Dieti^dans for HoGpitals. Journal 
of Hcna care. Vol. l. Ho. o2. 

Hsdisfil SiDQEd News. 1978. AMRIi: Ihe First 20 Years. August. 

FeV; M. 1979. Changing Radiclogic Technology Bdkicatian: Evolution or 
It^volution? Itet Z. Radiologic Itehnology. Vol. 50, Ho. 6. 

Finnegan, R. 1987. Oomuniaaticn to the ICM CQnnittee to Study the Role 
of Allied Health Fencmel. Ibeecutive Director, American Hedical 
Asaociaticn, Chicago. 

Firestcne, D. T., and D. Lehiiann. . Changing Roles for Changing 

Tines. Journal of Medical Tectino logy. 

GnawMald, L. R. 1928. Ihe ^%tudy of Riysiotherapy as a Vocation, 
Vaxt ZV. Ihe Riysiotherafc^' Review. Vol. 8, Ho. 5. 

Hardtfidc, D. F., J. I. Morrison, and P. A. Cassldy. 1985. "Perspectives 
In Rithologyij Clinical laboratory - Past, Present, and Future. An 
qpinion." Honan mthology. Vol. 16, Ho. 3 (March) . 

Hazertiyer, I. M. 1S46. A History of the American Fhysiotherz^ 

Association. Ihe Riysiother^ Reviev. Vol. 26, Ho. 1 (January/ 
February) . Reprinted in "Ihe Deginnings: Ihysical aherapy and the 
AF^." 1979. ftaahington; Amerian Riysical Iherapy Association. 

Hapldr«(, H. L. 1983. "An Historical P^mective on Occupational 'iherapy," 
H. L. Hcpkins and H. D. Staith, eds. Willard and Spadoan's 
Oocupaticnal Oherapy, Sixth BcLLtion. Riiladelphis; J. H. Uppiicbtt. 

Soeda, K. 1971. IWelve Years of the Registry. Cited in William, R. M. "An 
Introduction to the Itofession of Medical Technology." Ihiladelphia: 
Lea and Febiger. 

Journal of the Ansrican Medical Association. 1929/1971. Vol. 92:1052. 
Cited in William,. R. M. "An introduction ^-jo the frofession of Medicrl 
Technology." Riiladel^^iia: Lea and Febiger. 

Kami, K. R. , G. D. VrioB, and E. C. St. John. 1986. I^i^>ectives in 
Qinical laboratory Education. Journal of Medical Technology. Vol. 3, 
Ho. 2. (February). 

Ubaratoay Medicine. 1982. Professicnals Levels Definition. Vd. 13, 
Ho. 5 (May): 312-313. 



- 30 - 

iMirose, N. 1981 . iMMwwiiit and intarvmtion in Bnexgency MUrsing. 
Bati», N.D.: J. Bradt/. Cited in McKsy, J. I. 1985: "Historical 
Rendav of Keigency MBdioal Ser.viaw, EMT zoles, and OCT utilization 
in Bwigenc/ D^jaxtaents." Journal of Dnexgency Musing. Vbl. U, No.l 
(Januazy/Fetaniaiy) . 

lingwall, J. B. 1987. ■^Iteaait DBvelcpaentr in Service Delivery for 
zndividMls with Oaniunication Diaordars in the Uiited States. " 
pcsssitad at Haaan Canunication Disorders: A worldwide Perspective, 
7th mtamational Elte SyB|»siun, Halifax, Hov > Scqtia, Kay A, 1987. 

lunz, M. E. 1987. The Sqpact of the Quality of laboratory Staff on the 
Accuracy of laboraftaty Results. Journal of the Aaarlcan Hadical 

Mcflleman, E. J. 1987. Allied Health nnofessions in the Unitei States: A 
Simnary of the Origins, Dsvelopoent and Potential Futures of a 
Selected Sasple of Allied Health Fields. Background paper prepared for 
the Institute of Medicine Gcnmittee 'jo Study the Itole of AUied Health 

Wft!eman, E. J. et al. 1983. fteliminary Report: Ihe !)enand for and 

Siq;ply of Allied Health Rcofessioials in New Ygz)' State. Story Brook, 
N.y.: State University of New York. 

Motley, W. E. 1983. History of the American Dental Hygienists' Associ- 
ation, 1923-1982. Chicago: American Dental »/gienists' Association. 

Baden, E. P. 1970. A History of the American ^leech and Hearing Associ- 
ation. Neshington, D.C. : Ihe Association. 

Pennell, K. Y. , and D. B. Hoover. 1970. Health Marpower Source Book - 
Section 21, Allied Health Marpower, 1950-1980. Bethesda, M.D.: 
National Institutes of Health. 

Rcxacwjod, C. A. , C. N. Mann, J. D. Ftoington, 0. P. Haaspton, and 
R. E. Motlc . 1976. History of Itaiergency Medical Services in the 
United Stat^. Journal of Tkauma. Vol. 16, ho. 4 (April) . 

ammn, C. M. 1987. An Ujpdate on Supply Estinatfjs for Speech-Ianguage- 
r^earing RsrscRnel. Ufublisted paper. RL^ille, m. : American &)eech- 
language-Haaring Association. 

%ahr, T. 1985. 1985 ASHA Directory Sqpplenent. RxJcville, Md.: 
'Ihe Association. 

Tones, H. O., and A. Ehrlich. 1976. Modem Dental Assisting. QtatitBc 1 
Riiladelphia: W. B. Saunders. 

- 21 - 

U.S. Oepartnent of Oonnextse. 1987. Statistical Abstracts of the united 
States. Bureau of the Ooisus. Heishingtan, D.C. 

U.S. Deiiartaient of Health, Edbcaticn, and Welfare. 1979. A Report cn 
Allied Health BBrsomel. Naahingtcn, D.C. : U.S. Goverment Printing 

Nillians, R. H. 1971. An Introduction to the Ftofession of 
MadicalltehnQlogy. Riiladelphia: lea and Febiger. 




Oongrass dixectod thst thi« study "identif/ projected needs, 
availability, and xegjixcnenta of vaiious types at health care delivexy 
systoBB for 9aA type of allied health peraonnel.** m order to re^xnd to 
this ch arge, the OGnnittae had to xveolve sevsxal Iseues of soqpe and 

QSittlfc versus fliture "neertB, nvnilnhUity. and reauijBments'' 
ocnDdttae belisves that, given linited funds and tine, its greater 
ocntributicn is to pcovide its bast nnfionmiifiiit of future needs and 
veqoimnts for allied health personnel and its bast iienfMiniiMiiit of the 
kinds of adjustaents that %dll be needed to sect those needs and 
zeguiraBSibs. Mthaug^ recognizing that there is intense interest in the 
curruit situation, the oonnitbHs telieves ttiat aost of the study's 
xesouroas wuld have been needed to nJce a aystsnatic nffenrrmirnt of that 
situation, vhsrsas the future outlook is mre crucial to e jrategic 
plamingr and policy, lhazefan aost of the effort has gone into 
developing a picture at the future. To the extent that we becane aware of 
peroeiitions of current iaiaalanoes as we conducted the study, we report 

"Each tenoa of *^1th PfmnTftr As the charge iaplied ^^^3 

the oonmittee clearly recognized, it in neither feasible nor usefi ' 
consider needs and availability of allied health personnel collect, ely. 
Allied health ooBrrises ooofjations with varying labor nar)oet 
characteristics such as paths of entry, levels and types of responsi- 
bilities, wages and salaries, labor force wtriee and exits, and work 
sites. As a oonseguenoe, the situaticn nist be considered separately for 
•ach occupational field. The approach here has been to exanine 10 allied 
health fields in scne depth in order to illustrate the diversity among 
then. To the extent poesible, these fields are used as the basis for sone 
general oondusions about the future outlook. 

«Tfeeds...wnfi 'Taqn^TmBnte'* IVpo different approaches are isplied by 
the diarge. "Needs", as used in the context of health narpouer planning, 
refers to a namative idea of the luter and type at personnel required to 
provide therapeutic and preventive services to a defined populaticn. Heei 
is iisually defined independently of econcnic constraints. Danand, (or 
affective denand) on the other hand, refers to the nunber and type of 
pereomel regain jd to fill the available jobs and provide services for 
%tiich oonstBsra are willing and able to yey 

Ohe ocnnittm elected to assess the future needs and requiraasnts in 
terns of effective doBartd for allied health perscnnel. Ihis was besed on 
its judgnent tiiat this approadi is aiost uan^fui for realistic planning. 
However, in the case of long-tem care (Chapter 8) , the coonittee chose to 
take a patiant-oentered approach and examine the future need for allied 
health perscnne].. 



- 2 - 

Planniwf hmrlzcan Bie coBinittee Ml«ctaS the ysr 2000 for its 
prajectiom of fUtun dnand and supply. Baa^:3e naat of the base data 
an for tha ymr 1986, this decision aaans, in •ffact, looking ahead 15 
years. Ite xeoognize tha maaeuB tmoartainty that goes %rLth so long a 
horizon. Howaver, nary dacisions zequixe some nniumttmrit . of the future, 
however icu^, anl the types of decisions that affect the labor narket for 
allied health pnctitioraxs, such as starting or nodifying education 
progranb, naoessitate a long lead tiae. Gn balance, then, the decision 
V6B to t«!sa the long view. 

Data for Assessing Dnand and Supply 

The study vas linited to the use of existi-ig data as the basis for 
its «i f * i« i«H «- of doaand and supply in allied health fields because it vas 
not possible to design, field, and analyze a survey within the available 
tine, pczticular^^dth the lequiment for Office of Managnent wd 
Budget (CMB) approval of such a survey. Ohe paucity of existing data 
concerning allied health fields severely oonstrainad the oonmittee's 
«d»ili^ to carry out its charge. Thanks in large part to significant 
federal invesbunt in dervelopLng data bases in aedicine, dentistry, and 
nursing, pcwdous ZGM studies of thosa fields have been alble to draw on 
large flncunts of data and on regairenents and simply prpjections made fey 
the Bureau of Health Frofessions (EHP) based on thoee data. In the allied 
health fields, however, iata are limited. 

Nbnetheless, data do exist. Ohe Bureau of labor Statistics (BIS) 
collects infonnation on cnployment, earnings, and labor force behavior of 
a nnber of allied health ooo^tions in its ongoing analysis of the 
Uiited States workfaroe. The decennial censuses offer detailed 
infonntion by occupation. Allied health associations conduct surveys of 
their meniaers that provide invaluable data on persons meeting their 
UBoberstiip criteria. Associations of hoqpitals, nursing hones, and hone 
heedth care agencies collect data on enployment in their constituent 

Ihese and other data sources have been CKBoined to inform the 
ccmnittee's assesansnt of svqpply anu danand. We point cut problems and 
weaknesses in the data below, and offer some suggestions for isprovenent 
that, if hsedad, %dll make an easier tasik for future grc^ps. 

Assessing currant Dnnand and Supply 

Hov do we know if ttmn is a current Aortage of allied health 
personnel? Ihis is not a straightforward question. First of all, the 
f^r r> diortage has a variety of naanings. Sonetimes it is defined 
normatively: a titacta^ exists if there are fewer respiratory theri^ists 



- 3 - 

than ate naedad, aooozding to maoB defixiition of need. Ekxnonists define 
a dxsrtage as fewer people nployed than «ni>layexB would like to enploy at 
the ouixent wage. Althcu;(h cognizant of other factars that influence 
«ipIogf«rB' decisiora to onploy iiorkecB and pcoepective eqployees' 
decisiaw to aeek uodc, eooncnists traditionally focus on levels of 
julnirlfa and wages, and ■cnetiiaBs en firinge benefits, as the principal 
variabla tliat serves to aquilifaFBte aooployer denand and labor sctpply.-*^ 
Aooording to theory, if the labor aartat ware functioning prqperly, a 
shortage oould eodst only taofccarily, because aployers would pay nore to 
attract nora wockars until all jobs ware filled. Ohus, economists view 
the eodstenoe of any labor shortage as reflecting aither lags in the 
adH'JstMit of sivply to denand, or iaperfactions in the Anxtioning of the 
labor nrket. If denand grows at a nqpid rate over a period of tine, it 
is possible for there to be a taqparary dicrtage. Barriers to adjustnent 
can result in nvply and denand not ocning into balance. These will 
be iVwrlhotl later. 

A ^nctage can be rinrt-run or long-run, althcuc^ long-run shortages 
are unisual ixnless there is some market ii()erfection such as a price 
ceiling that pcdiibits market adjustments. In the short run, workers nust 
be recruited fkan M» existing pool and aqployers mjst use existing 
technology. In the long run, however, new imrkers can be trained and new 
technologies oiployed to change the nature of the inrk. 

Indicators of a labor Shortage 

A nadser of signals can indicate that at labor shortages exist. Ihe 
signals include hi^ job vacancies, rising ccnpensation levels and lew 
unenploymsnt levels. 

^jjf MTn<ftg The nost ocononly cited indicator of labor shortage is job 
vacancies. A hi^ naber of vacant positions or ratio of vacancies to 
total oiplo^nBit i» taken as evidence of a diortage. "Hic(h", of ocurse, 
is relative to sceie expected level of vacancies. Ihis expectation nay be 
based on historical vacancy levels for the occupation of interest, or on a 
ccBfarison with current levels for other ocaqpations. 

Some vacancies exist at all tines because of job turnover. Because 
jcb adsility is isportant to a well-functioning labor market, nich 
vacancies can be visued as a sign of health rather than pathclogy. As 
Hall has pointeJ out. 

The role of vacancies can cnly be understood against 
the badoground of the ceaseless nation within the labor 
nxioet. . . .Every aonth, several nillion iKarkers change 
joias, and hundreds of thousands of others nove in and out 
of the labor foroe. Hich of this turnover is attributable 
to fluctuatiora in the labor re(|uirBDents of individual 
flsployeni and the rest to the changing circunstances of 
individual wockars (Hall, 1978) . 

^Ohis is soneuhat aversiaplified because other aspects aich as the risk 
involved in work and working oonditicns are also ocnsidered in eooncmic 
analysis of labor denand and n^ply. 

in 61 

- 4 - 

Vacancy rates ara not raliable iidlGatcre of jcab opportunities 
for several raasons; the hic^iest rates oocur in oooupations %iith the 
hic|hest turnover; construction %Poirk is an cmnple often cited. Amcng 
the health oocqpaticns, turnover is nuch hi^^ for nurses' aides than 
for hiq(hly trained persomel such as ledical technologists or ph^'sical 

Also, reported vacancies should be vimed with caution. 
Vacancies do not alMq^ represent a ahortage. If, throug(h rjne 
BBchanian or another, wages are kept bela^ the level that vould faring 
sqpply and denand into e^iilifariin, cnployer denand %dll rlways eoaseed 
the nater of allied health persomel %ho vent to %PQrk d the going 
%feie. Such exoess denand omnot really be characterized as a Aort&ge, 
but rather as an iaperfection in the operation of the aarket. 

Sloan (1975) , Yett (1975) and others have pointed out in the 
coritext of nursing that if the labor aarlcet is not ccepetitive and 
therefore one or several enployers have some ocntrol over the wage 
level, the aartet can be in aqailitarlw %hile vacant jobs exist. Such 
an cnployer vould report vacancies but not raise wages in order to fill 
than. Another possibili^ is the systenatic undervaluation of work in 
oooupations in \Jhidtk female woxloBrs predoninate. Institutional 
barriers such as long-standing custom, aieperoeption of aartet 
conditions by eqployers, and inflexible recruitment practices aay 
account for vacancies, rather than an insufficient nunber of gjalified 
persons available to work. 

Qcnpcnsaticn levels Another signal often interpreted as indicating a 
shortage is rising coqpensation levels. Nages are the nost easily 
observed, but ocnpensation in this case neans the entire package 
offered by cnployers: wages or salaries, benefits, hours and 
conditions of work. If enployerB are not ddle to attract workers with 
the current package, tiiey prHumably will iapnove it. increases in 
conpensation Ic/els, however, are not in themselves evidence of a 
dxxrtage. Rather they oan indicate normal, and often tenporary, auket 
adjustnents in a situation of rising denand. 

Relative changes in ocsfansation levels are better indicators of 
labor narket conditions than are absolute chancres. If physical 
therapists' aaminge axe rising such faster than earnings in, for 
axanple, aedical technology or teaching (fields regoiring sinilar 
educational investanents) , and if cnployers are unable to fill vacant 
positions for pl^ical therapists, we ai^ conclude that there is a 
tfiortage, or at least tiiat at pracont donand is outstripping simply. 
If narket signals are sufficiently strong (that is, conpensation rises, 
unenployaent drops, etc.) the riiortage presumably would be 



- 5 - 

allwiated over tine by new antrants to physical then^. However, the 
interim nay faring painful dislocatlcns. Services nay have to be 
oirtedled, or eutetitute workers magla^9d at an unacxseptable deczeient 
in ^lality. In aoM izriUstries, of cnurse, such dislocatiora are 
viewed as nomal. 

PieBPlewinent I^welg Soma tricticnal unaploynent (a level of 
unBBplcyment resulting fran the time involved in changing jcte) is 
tiiaracteristic of a dynamic labor narlcBt in vliich pacple change jdas, 
often with an intcrvKl between jobs. TtanplcyfflBnt levels will tend to 
be relatively hi^^ in occqpoticns with high turnover. Very low 
unn|)loymmt levels, whan viztually everycne seddng ai^^Loynent is 
finding it, is another signal that nay indicate a labor shortage, ihis 
«nuld be eqpecially true if vacancy levels main hi^^. 

The oggployneiit e9qperienae of new greduates is one indicator of 
conditions in the Idxir naxlcet. If, for instance, nost fiiysical 
therapy graduates find work in the field within a year after 
graduation, the labor narkat nay be ti^. Ite %dth the other signals, 
caution in interpretation is needed. Maw graduates can be hired at 
lower wigres than eaqperianoed thenqpists, and scne cnployers nay prefer 
to substitute less experisnoed i4orkers for nore experienced ones in 
order to keep oosts down, m addition, new graduates t«nd to be nare 
mobile and therefore their aoqperienae nay be nore favorable than 

Any one of these signals alone does not indicate a shortage. On 
the other hand, when a nunber of then occur together, e^-^ieQly if 
they persist over tine, the nore likely it is that there is a real 
pcdblen. If enployers are constrained traa naking adjiistnents such as 
substituting lesser trained enployees (for exanple, corrective 
thereqpists for physical thenqpists) or iifxirting workers frcn ebroad, 
or if the necessary adhjustnents are unacceptable to society, ix. would 
be fair to call the paxblem a labor shortage. 

Data for Assessing current Vacancies 

Khtional data on job vacancies are not available. For both 
technical and budgetary reasons, the Bureau of labor SKiatistics (ELS) 
does not collect vacancy data. Ihe American Hospital Association (AHA) 
collects data on allied health cqplcyment, but not vacancies. 
Qualitative assesenents are often made in surveys of local cnployers 
by, for CKBiple, education adninistrators. Surveys by professicnal 
associations nay include questions about aeniien' peroeptions of the 
labor narket in their comounities. Anecdotal data is zeported in 
health care journals and nawslettere frcn tine to time. Regional or 
state developnent bodies such as the state-sponsored Massachusetts 
Technology Developnent Oarp o ra t ion try to make assessments. 


Data en Salaries and Itages 

Ihe EES LnAistxy Mbge Survey pgogtam ooUacts an) publiahes 
average strai^-tiae hourly %ia99s for aelected oacu;pdtlons in 
hospitals and lairsing hcnes in 23 Standard Hetrqpolitan statistical 
Areas (SMSta) . Hospital surveys were oonductsd in 1978, 1981, and 
1985; allied health ocxaqpaticans oovsred include diagnostic aedical 
sonographers, electroanoephalogFaphic technicians, electrocardiographic 
technicians, aedioal Itfxratory techniciana, eedical technQlogists, 
ludear sadidne technologists, radiaticn therapy technologists, 
xadiograchers, surgical technologists, all the therapy ooccpations, 
dietitians, gftdioftl xeoocd adkninistratorB and technicians. The survey 
excludes eloents of nrwrigiBiiticn such as pmiioi pay for overtime and 
work cn ni^ ihifts cr hblidays, and in-kind cyjuwiiw i t i nn such as room 
and hoard. Ftinge benefits also are excluded. Iheee data are very 
useful for examining trends in basic iiieges in urban hospitals and 
nursing hones, and for oonparing %iage levels among SMSAs. 

Oooqpational earnings are, as noted earlier, available fkon the 
Qirzent Rspulaticn Survey. Earnings of association aenbers are 
oollected in lober surveys. The Uhiversity of Texas Medical Branch at 
Galveston does annial surveys of 33 hospitals, 16 medical schools, and 
28 Mfidi«i centers. 

Uhenploynent statistics are collected soithly by ELS. Although 
extrenely useful in aggregate, these data have scne veaJcnesses in 
assessing market oonditicns in specific ooo^ations. Uhenployed 
perscns are classified by oooi^tion according to that in ^ch they 
were last enployed. Ohus, a person seeldng work as an audiologist 
%dhose last job mis as a teacher would be CLtegorized as an unenployed 
teacher. Heoent graduates seddng their first jcb are excluded tram 
the unenploynent figures lay occupation. As with other market 
indicators, EL5 ocaqpational unenployment data nust be used carefully 
and critically. 

Surveys by allied health professional associations generally 
include infomation on whether their menherB are oployed and where, 
less frequently do they include information, such as whether the 
re^)ondent is looking for woiic, that would cxaplenent data trcm the 
current Popjlation Survey. The Ooranittee on Allied Health Education 
and AocrediVation (CAHEA) has conducted surveys of education p rog ra m 
directors about the offers to their graduates as a means of assessing 
the job inrioBt. Seme state education departments conduct similar 
surveys. Scne individual educators survey enployers in their ocnsunity 
regarding aqployment opportunities. 

How to LqpnTwe Data cn Qimnt Supply and Deoand 

Hhe current balance between supply and donand for allied health 
personnel is of oonoem to a %dde range of organizaticns, edncatorB 
omio e m e d about jcsbs for tiieir students, facility aAnlnlstnitare oonoexned 
about the availability of needed perscmel, allied health practiticners 
and their associations o o noam e J with jobs, ocqpensation and career 
proepects. Ih functional tsm, an aewneianwit of current siqpply and 
denand is the essential baaeline data point fran which projections start, 
m addition, current InfanBation about the labor sarkst enables those in 
positions to do so to act early to prevent the oo uun snoe of serious 
iibalanoes and the later need for aajor ooKrective action. 

Me have listed the types of data needed to sake an astinate of 
current sqpply and denand. Sone types are available, usually for only 
aa mied health fields in sone localities. Health care iistitutions 
already reapond to heavy denand for operating data and are reluctant to 
add to their burden without believing that such data will serve their 
interests. AddiUonal data ocllection ectivitiee tfiould be undertaken 
only after careful ocnsideration of the benefits of such efforts and ways 
of sdniaizing the burden of providing the data. The data to assess the 
current labor nrket conditions are more available fbr aone health 
profeesio«iB-«ich as physicians and nurses— than for allied health 
fields. The ocmnittae believes that lack of da"^^ about allied health 
fields oczparad with other types of providers reflects an underestimation 
of the role of allied health. Both the large contribution to care that 
practitioners aate and the hiq(h total costs associited with aggregate yjose 
of allied health professionals strongly suggest that data collection 
strategies that allow aenenniiinnt- of current supply and denand should be 
seriously coq;>larBd. 

Associaticns of cnployers could try to develop siaple, inexpensive 
surveys to learn about pccblens in recruiting; for exanple, what kinds of 
cnployoes are you having the most difficulty recruitin,? Are you using 
any eoeoeptional neasures to recruit? Miat actions are you taking to 
cope? Ihis ni^ be done in a very snail sanple of "sentinel** 
institutions as fk«quently as twice a year. 

Rofessional associations should use standard terminology of labor 
statistics to increase the usfeAilness of their surveys to ELS and vice 
versa. It is eeqpecially inpartant to ooint people who are not working but 
are actively se^dng work; these are the pecple the U.S. Dqj ai tii m it of 
labor oatagorizes as unenployed. nn>fessianal associations should eaqplore 
longitudinal studies of a sani>le of their weabm to ahed better light on 
their work histories, labor foroe participation, earnings, etc. than iF 
possible fron their usual cross-sectional surveys. In addition to 
technical iaprovanents, associations elnuld look for ways of naddng tlieir 
A e setULii aore relevant to policy. Associations would be well served to 
s U wy tl iai the lirdGS between their research and policy functions. 

- 8 • 

HRSA ateuld noonstitute the Itmas an Allied Health Data as a 
tachnical asBlstanoe andeovor, and hold vort :3ps %dth experts in survey 
design, statistics, and labor maanssdm to help the allied health 
associaticns ispraw their data collection. Other possibilities for 
iBpros^ing the Infamtion on current labor narioat co n di t io n s for allied 
health personnel Include the foUowingr: 

o State liceraing bodies could ask, %hfin renewing licenses, if 
people are currently oqployed in ttieir field, enployed in sonething else, 
loolcing for ^*ork, or not looking for %«rk. 

o State and regional health planning agencies could sake larger 
investinents in education and eoplo^ent data and planning. Ihey could 
pro/ide an iainrtant lihk with education institutions and cnployers. 

o Educational institutions could pod Inf onoation on the 
job-findii^ experienoes of recent graduatas and al\soni. Local esq^erienoe 
could be aggregated to develop a state and natiorjal picture. 

Assessing Future Demand and SappLy 

l^pjectiora of the fiiture go wrong either because they do not take 
the proper f actcrs into account or because the factors change in %»y8 that 
vere not or could not have been predicted. However, decision making is 
based on assunptions about the future, however czudely farmed. Our task 
has been to use the limited data available to make our best guess and to 
let that inform our recGnnendations. Ne have made reccnmendations based 
on interpretation of general trends in the work force and the eocnoa/ and 
of pacific projections for selected allied health fields. 

Several aipxiachas are available for assessing f Jture needs and 
requirements for allied health personnel. Some approaches that have been 
used for other types of health manpower care described below to illustrate 
the options available, the vays they can be used and the types of data 

Heeds-based prpjactions usually define the nunber of personnel that 
vould be needed to provide a given set of services to a defined popula- 
tion. Ihe ne^ds approach, vhich wus pioneered by the Oamdttee on the 
Oosts of Medical Care in the 1930s, involves two types of judgnmt. One 
is of the quantity and type of health services judged to be appropriate, 
and the other is of the appropriate division of responsibility for those 
services among the various health personnel. Dqpmding on idho makes 
these jxidgments and their views of %tat constitutes good health care, the 
results can vary greatly. 

Ifae Graduate Medical Education National Advisory QGnoittee, 
appointed by the Secretary of Health and Human Services in the late 
1970 's, enployed a needs-based approach to project physician reguir^eroents 



- 9 • 

for 1990. Hm ocmdttM started %iith astiiDates of the incidenoe of 
partloular illiMses or UBdloal auditions in the population and then made 
judgments about %teit :xnditionB reqioiined nadical oare, hov many visits 
%culd be reguixed, and hov nany of those visits nic^ht be ''delegated** to 
pezBons other than physicians. Tctal visits vere transfonnBd into 
physicdan VHSoirenwits based on assuqptions about productivity (Jacc±y, 


A Bodel of reqioiments for nxrsos developed by the Western 
Ihterstate OGBnission on Hi^^ter Bducation also had its foundations in 
judgmoits of need. Buials of nurses prcvided professional judgments about 
desirable changes in health oara delivery and about the mix of naxses, FNs 
and UMs, nMded to prcvide the desired services (Bauder, 1983) . 

Ihese needs-based lodels l e pn es cnt an unoonstiained social idezd. 
They axe nanos against uhich to ocnpare actual perfomanoe. Ihey can be 
used to establish health care pr o g r a m cbjertives and to aesoss the 
probable atvailability of personnel to net those objectives. 

Another approach to projecting health wsrfamr reguirenents is to 
extrapolate trm cunwit levels. Instead of assi^piing ideal health 
servioes utilization levels (and their oor t esponding health personnel 
regoimBnts) to p rojected population segments, current utilization levels 
are projected. Host sisply, current health persomel-to-pcpulaticn ratios 
are api^ied to population projections. Ihe Bureau of Health ^fessions 
uses ttds wthod to project physician reciuirenents by starting with 
current utilization levels and then adjusting fbr projected changes in 
population, trends in health insurance benefits, and other factors 
affecting utilization such as prices of health servioes. Productivity 
assuiqptions are used to translate projected utilization into the nuni3er of 
physicians required. The Division of Ntirsing also enploys a model that 
projects population, per-cqpita utilization of health aervices, and the 
associated nadaers of registered nurses and licensed practical nurses. 

Ihe sinplest of the extrapolation models is strictly mechanical; the 
health p e rsonnel-to^population model is an exanple. More sophisticated 
nodels incorpor a te la^iavioral" ocn(x»ents, such as the price elasticity 
of demand for health servioes, end make independent projections of 
prioes. Ih^ also may inoorporate changes in production technology such 
as ceqpital-labor substitution, or the division of tasJcs among health 

As extrapolation models beccne more sophisticated, they mor» 
resenble mSels of econcndc demand. A denand model is based on the 
relationships of independent variables such as health status, inocne, and 
prices, to the donand for health r^arvioes. Ih the case of labor deeoand, 
the nodel is based on vaid^^es suuli as %iages, the prloe of capital, and 
product prioes. Althougfh not strictly a demand model, the Bureau of Labor 
Statistics pr oj ec t ions of cnploynent are made in the context of p r oj ec t ed 
labor force and economic activity. 


- 13 - 

Hhe cxmdttae chose vo rely heavily en the axploynent p rojections of 
ELS for its Mseatiiiiei'it of future donand* Ihe principal reasons for doing 
so %iere: 

o *Ehe BIS projections era yiuuitl a d in projections of the entire 
eoonon/, induddng projections of the voilcforoe and levels of eoGncndc 
activi^. Haalth eoqpenditures and health industries enploynent are 
estimated in the context of growth in other types of expenditures and 
enployment in all other institutions. 

o Ihe p rojec t ions uee a consistent sethodology ecross occipations. 
riot only can the allied health ocopations be ocqpared with each other, 
they can be viewed in the context of all other occupations, for which 
p rojec t ions have been aade in the sana wey. 

o The projections are %ridely known and ueed, and are reviewed 
regularly and revised biennially. 

We did net. however, use these projections uncaritically. Several 
factors wst be taicsn into account when using the ELS data: 

o Occupational enploynent projections are subject to considerable 
ennor, aoraso than totid enploynent by .industry. 

o Ihe BIS staff use their knowledge and judgment to project the 
mnber of jobs for each occupation in an industry. For the health care 
industry nany jidgnents have to be made about how changes in health care 
financing and delivery will infMict different oooiqpations. Since these 
judgments are not publishad it is difficult to subject the results to a 
critical assesanent. 

o The OQSUt^tional definitions used by ELS are not identical with 
those of professional associations or educators. Although great 
iafxrovements have been nade in ocr^ational classification, BLS 
definitions rely nore heavily can ftnctions and less heavily on 
credentials. Too, the data are not adeqi^ate in some cases to distirguish 
different levels within occqpations. For instance, the BIS oonbine data 
for laboratory techndogxSts and technicians. In eone instances, as for 
perfusionists, dialysis technicians, and cardiovodcular technologists, no 
CBplcynent p rojec t ion is aade. For further discussion and evaluation of 
BIS data aee Appendix V. 

How EES Makes Biploynant ftorjecticns 

Because the cxanittee relied heavily on the Bureau of labor 
Statistics for its aeneBfnngnt of future demand, it is ijqportant that the 
reader understand how these p rojec t ions are sade. Ihe Bureau of labor 
Statistics p ro j ec t ions are nade fran a base year to a target year. Tiie 


base for their nost reoent pr oj ec t ions watL't 1:986; the tea:get year was 
2000. In a badoground paper pcepared for Im ocmnittee kiy Harold 
Goldstein the BLS sfproech was characterized in the following 

Htm basic approech f olloMd is to tstiiu^te tte 
enploynent in sach oocqpaticn that will be g^nanrtad by 
magradc dnand. nils goes back to the doand for the 
goods or servioes the oooqpation pco^ddes, and this in turn 
is affected by the total spendable inoGoa available to 
ocnswexB and gc^mmDent and to the cSumgingr pattern of 
itet tiiey qpe It on. Itese are influanoed by a vide 
variety of social and iiooraaic fiictors, ixdixUng changingr 
tastes and styles, sciintific diaoowiehi and technological 
change affecting both is prodooed axvl hov it is 
produoed, ttm growth and changing ocnposition of the 
popcTaticn, taxation and gcvemnant eoqpenditures policies 
('guns or butter'), and vhat other ocuntries are baying 
frcn and selling to us. (Goldstein, 1987) 

Several steps ure involved in the prpjecticn seguenoe, the first of 
^ch is the projection of the labor foroe. Ttm foundation for this 
projection is the Cei^sus Bureau's pqpulaticn projections by age, sex, and 
race. Iheee projec t ions are based cn assunptions cibout birth rates, death 
rates, a. Jl n^pntion in and out of the Iftiited States. Ihe labor foroe 
partic^ticn for each age-ee)c-zaoe qto^ is projected >y extrapolating 
past participation rates. Ohe projected labor foroe participation nites 
are applied to the corresponding population projections to arrive at the 
pro)ected labor force in the targrt year. 

Next, BL3 uses a nacroeooncndc model to develop projections of Gross 
National Rnolict and major categories of denand and inocne. Seme of fiie 
assunptions affecting the macroeoonondc model, such as population 
projections, are fairly certain; other assunptions, sixh as ret imports, 
energy prices, and the exchange value of the dkdlar, ar& very uncertain, 
depending as they du on international political und econcnic 
develop ^its. Because jissuLpticns about cert^tm ivj varlahles have major 
ijipacts on the projec t ions, BLS prodooes four sets of naczoeooncnic 
projectiors based on three eets assunptions. lliese assunptions are 
about level of experditur ^ in aajor oonponents of federal saoending, the 
major ocnponeiics state and looal gc^wcnoBnt ^pending, t^ \zb and 
oonposition rf the population, and the key variables underlying foreign 
trade; low, medium, and hi^ projartions of a<P are made fron f^jffering 
assunptions for each of these variables. 

- 12 - 

Belov axe aam of the assuiptlors that vera used in the 
poxijections for 2000: 

Fadexal datese qpenUng 

($ billicns) 222.5 251.0 263.0 

Fadexal nondef arae qpeniing 

($ billionB) 97.3 103.4 108.2 

State and local apending on oducaticn 

($ billions) 195.3 223.1 232.5 

Civilian labor focoa 

(millions) 134.5 138.8 141.1 

the etxect of these variations in assunpticns can be seen in the 
iiqpect on Gross National tkoduct, and aqplcynent. Ihe low, noderate, and 
high prciections of Gross National Vvo&jct resulting frcn these and other 
iissunptions are (in billions of doHara) $4,617, $5,161, and $5,5S2. Ihe 
oorresponding projections of total cnploynent (in thousands) are 126,432, 
133,030, and 137,533 (Monthly labor Review, SflpfCTitier 1987) . 

Next, BLS estimates the prind^d ocmxaaaiL s of GNP: personal 
oonsunptlcn of durable and nonduxable goods and sexvioes, ce^ital 
investment, foreign trade (inports and eaqports) , and govemnent 
eaqpcndlturas. Ihese estimates of final demand are trare''. 'jui into 
estimated levels of ;,codix:tion for each indistxy in the ^urxMo/ using an 
input-output table, based on historical ijlatloi^iips, ocnplled by the 
Oepaxtnntt of OGnmeroe. Ohe irput-output table «hat each industry 
in the eooncny purchases frcn evexy other industxy. Far exanple, the 
autoDKibile indistxy purchases rav materials (iron ore) , intexnediate 
products (tires, glass) , and sexvioes (electrical power, trar^xartation) 
frcn other industries in oeiter to produoe its final product, autondbiles 
(Goldstein, 1987) . Ihis step results in estimates of the level of 
production for evexy industxy in the t2irget year. 

The neoct-l'o-last step ot tiie prooess is the estimation of total 
coployment for each industxy from a regression eijuaticn that estimates 
WDoicer-hours as a function of industxy output, the unaployment rate (a 
measure of capacity utilization) .. the ral/itlve price of labor, and the 
ratio o£ outvt to capital. The estimated wcker-haurB are translated 
into woricexs dividing by estimated amual hours per worker. 

Finally, the BLB develops estimates of ooo^tional enplcymETit fay 
industry, utilizing base-year data on the distribution of indiTsstxy 
flnplOjTQBnt by ocapativT.. Sources of data include the Ooctpational 
Bi|>loyment Statistics (CES) surveys conducted periodically by state 
oployment security agendee isider a GtS-statn oooperative pro g r am (see 
Aipoidix V for discussion of CES and other d>^' i aouroes) , the Deceomial 
Omnsus and the current Population Survey, m projecting ooB^tlonal 
jsplcyment in each industxy, adjus^inents axe made in the ooopational 
oonposition of the industxy. 

ERIC 70 

- 13 - 

The health aervioes industxy is taodken into oaqpcnents oocposed of 
tha different aettixigB of cqpliynent, such as hoqpitals, physicians' 
offices, and nursing hones. Oha next step of the pomess takes into 
account factocs not «oq)licitly included in tin BBthenatical nodel. BLS 
analysts with xesponsibilitias for qpecific cocupaticra consult oqierts 
suci^. as pcofessional aascciations' staff, use the relevant literature, and 
■Bks site visits to aaaese whether staffing patterns are liJoely to change, 
and hov they %dll change. Becauee the aggregate .^cyoent for each 
industry provides thm paraneters of oiployBent, EES analysts confer with 
each oOier to determine how each occupation in each industry will fare 
relative to one another. For eBtanitle, the analysts who follcw health 
occa^pations will net to discuss teepitAl staffing patterns, what changes 
are expe ct ed and why changes will occur, nctocs taken into account 
include^ new technologiss likely to change staffing intensity, changes in 
insurance coverage, and ragulrtocy policies influencing the demand for a 
service or individual ocxxpaticn. 

Table 2.1 itesws tiie low, soderate, and hi^ projecticns of cnplcyosnt 
in allied health fields for 2000. Differences among the three projecticrfi 
are attributable only to different assuofJtions about eoonondc growth and 
aggregate cnplcynent. Ihe sane assunfjtions about and adjustments to the 
occupa t iona? distribution of cn{>laynent are used in all three. 



- 14 - 

TKEUE 2.1: Bureau of V ihor Statistics ftage and Salary Bq;>layinent, 
Actual 1986 and Rnojactions for 2000 

1986 Brpleetfld Bmlovnent gnQQ f^^io^n^c) 
Oocupaticn Bqployinent Lav (a) Hoderata (b) Hi^ (c) 

Clinical laboratory 
Technologists and Technicians 





Dental Hygienists 










Baergency Medical Technicians 





Medical Reoord Technicians 





Nuclear Medical Technologists 





OooipatlQnal Therapitfi:;;; 





Riysical Iherapists 





Radiologic Technolog.ists 
and Tedmicis^is 





Respiratory Therapists 





Spooch-Ianguage Pathologists/ 





SOURCE: Silvestri, G.T. and Zukasiewicz, J.M. 1987. Monthly labor Reviev, Vol. 110, 

No. 9 (S^ptCBijer): 46-63. 

a) Lew projection represents annual growth rates of 1.6 peruent in GMP, 1.0 percent 
in the civilian labor force, and 0.9 percent in cqplcyment. 

b) Mcderate projection represents annual growth rates of 2.4 percent in GNP, 1.2 
percent in the civilian labor force, and 1.2 percent in eggployment. 

c) Hi^ projection represents mual growth rates of 3.0 percent in QH?, 1.3 percent 
in the civilian labor force, and 1.5 percent in aoploynent. 



- 15 

nxture S^qpply 

In & dynamic labor mrl c, tiia mipply of %ror)c8rs in an oocqpaticn is 
OGnstantly changring. Hav graduatas anerge Iton educatiGn p rog ra m s . Poople 
anter tha labor wuicat vho have wockBd in other oocif)atiais or vho have 
atudiad related aubjects. Faople leave the vorfc foroa and later re en ter; 
eone leave peznanentJy. 

Rpjecting future supply requires, first, estinating how nny people are 
in the field in a base year, and ttien estinating the various inflows and 
outflows ttet will oocur between the base year and the target year. 
Miich inflows and 9'UIowb are iiportant depends on the purpose of the 

For aocanple, in nursing, there has been conoam that there are nany 
trained nirsas %Ax> are outside the nursing work foroe, working in other 
fields or, not working at all. Althoug^h data m licensed nurses provide a 
picture of those nurses who lonp their licenses active, sane have argued that 
ttmn say be aany nurses who have dtmjp e d their licenses but ylho, in seme 
sense, constitute potential simply. If sarket conditions iiarrant, the 
argianent goes, these nurses could be attracted back to vnrk, even if some 
retraining vera necessary. This pool o[ trained vorkers can be estiinated, 
and projected, using data on the nnber of graduates and applying standard 
iQortali^ rates to each age gccujp. The si^y estiinated by this life table 
approach represents an estinate of all living nursing graduates (West, 
1983) . For this purpose, the or / inflow i^ new graduates and the only 
outflow td death. 

If the question is, however, whether there be enoug|h nurses to fill the 
jobs that we expect to be available in the ftxture, nore inforiiation is needed 
about the likelihood that the ones who are not in the laaik force will 
re-enter. 19a also need to toiow about the likelihood that those who are in 
ttm work foroe will leave. Variations in the rates of re-entry and loss from 
the labor force and the average tiae i^ractitioners qpend in the labor force 
aake large differenoes in the supply projected for the future. Fsr nost 
purposes, in other words, it is the "effective** si;qpply of health personnel, 
trained and wanting to work, that is of greater interest. 

Ihe ocnnittee has, wliere feasible, projected what the future supply in 
allied health fields would be in ttm year 2000 if inflows and outflows from 
t^ia labor sarKet were to renain as in 1986, and if allied health program 
graduates remained at the current level. Ihese assunptions are unrealistic, 
but are used to indicate the magnitude of change that must take place to meet 
future demand. A siaple axit^/ stic equation vas used. The %«icforoe at the 
beginning of one year was said to equal tha wikfuiua at the beginning of the 
year before, minus persons leaving the warkforoe for reasons other than 
uranploymait, plus graduates of allied health yiugiams and other additions. 
Ihese additions include people resimdng work and people transferring frtn 
other occupations. 


Ihe base year for cur observations ws 1986. To achieve ooparability 
among fields, the BL6 estimate of total enployident for each oooqpation vas 
used. An estimated umber of unenployed practitioners %ias added in each 

For some allied health fields the nmber of graduates in 1986 %ris assumed 
to remain constant througjh 2000. Iten it vas reasonable to do so, the 1986 
ihare of bactelar's degrees granted in a field, relative to all bachelor's 
degrees granted, ws acplied to the Omnter for Education Statistics' 
projection of bar ^or's degrees to be granted wch year throng 2000. 

Labor fbroe aooession and separation rates that the Bureau of Labor 
Statistics derive ttm Current Papulation Survey iCSS) data were used to 
determine additions to and losses from ttm w o rKfu ioe> Because the sanple 
size of most allied health fields f Ji the CSS is nail and estimates subject 
to lozrie sanpllng variability, w used rotes of labor fbroe aooession and 
separation for larger grcups. For exanple, the rates for tiieraplsts overall 
vere applied to physical, ocnjpational and respiratory therapists, m 
«(}proodmating additions to the wa ri cfo roe, the aooession rate for 1983-84 vas 
applied to the 1984 vorkforce to generate an estimate of the nurnber of 
persons «ho joined the vorkforoe in 1984. That nmber %ris held constant each 

In Chapter 4 ve bring together %tot the coomittee knows about siqpply and 
demand for allied health practitioners. Ne evaluate the BIS cnployinent 
projections for each field to the year 2000 in li^ of expectations about 
the^ forces that drive demand. Ihe results of the process to estimate simply 
(3h3scribed in this chapter are oonpared to expected demand. To this lae added 
knowledge of haa the fields are faring in the current labor markets and in 
the tr«ids in nunbers of graduates and pro g r -a ms to mske an assessment of ^ 
future balaiKse between sqpply and demand. 

Data for Rnojecting the Future Supply 

current (Base Year) Siqpply 

Ihe BIS Industry-Oooqpational Edploynent matrix provides an estimate of 
the number of enployed persons in each of 480 ocapations. It is not an 
undi^icated count; wage and salary irarkers holding two jobs would be counted 
twice. Ihe most recent data, used as the base for eqploynent projectiais to 
the year 2000, %pere for 1986. Ihe next year for which these data \rill be 
a^dlable is 1988. 

The oodvational classif ications UMd in the CCS, the principal scuroe of 
data ^or the matrix, are consistent with the Standard Oonqpaticnal 
Classification used by all federal agencies that collect data. They 
represent a balance between conprdiensive coverage and quality data and the 
ability (and willingness) of eoBplcyers to respond. The current definitions 


- 17 - 

used in hoepitals appear in Appaidix m. These categories and definitior's 
should be cxxitinually evaluated and axxlif ied, if neoessary, to accurately 
portray the allied health vorlcroras. 

Ihe other data eouroe for exsaining the base ynr Avply is naDberiGhip 
data from allied health associaticns. For fields that are >«ell defined and 
have a single route of entry, and in %tiich the associaticns represent a vezy 
large pcoporticn ct the field, as in oocqpad^cnal ther^ry, this usually is a 
good est^Bte. For aany allied health fields, however, association 
weatjeaitdp data are incciii>lete or noraxistent. See ^)ppendix IV for 
discussicsn of different sources of data on simply for each field. 

Hsv Bitrants 

For fields in which the bachelor's degree is the encry level, there are 
two main sources of data. Ihe U.S. Department of joduoaticn oollects 
historical data en degrees awarded by field of study. Ihese data include the 
allied health fields of oocqpational thereby, physical ti^arapy, dental 
hygiene, wdical record librarianship, BBdical laboratory technologies, 
radiologic technologies and speech pathology and audiology. Ihe Center for 
Bducaticn Statistics periodically vakes prpjecticns of tha total nunber of 
bachelor's degrees, and the nunber of awards to nen and wcsien. These 
projecticns are based en natheanatical projec t ions of historical trends in 
oollege^ing by different age groqps. As rtlflnisflffi above, the oonnittee has 
proj ec t ed new entrants fkon bachelor's degree p rogr ams in seme fields by 
assuming that the field's share of bachelor's de grees in the years 1987 
througlh 2000 will renain constant at the 1986 level. 

Ihe seocnd principal source of data m new graduates is the bodies that 
acui«lit educatlcn prugrams. GMIEA is the largest, representing 24 allied 
health field oocqpations in 1987. Others include the Ar^ic&n Rxysical 
Ihenqpy Association (AFTA) and the American Speech-Iaraguag^ 
Itearing Association (ASHIV) • Historical figures on graduates can be 
CKtrz^lated for the future to estimate ftiture rmt entrants. Individual 
states can use data fkom their own higlher education institutions. 

Other Inflows 

The weakest links in p r o jec t ing flitura supply are the data for estijiating 
entrants frcn outside the labor foroe, Cram other oocqpations, and froa 
abroad (iBmigrat^on) . Iheee inflows (and cdxrcring 
outflows) represent very iji|)artant Aart run lahnr market adjuflrtsnent 
■echanisDS. Ihe BL5 staff has made sone ^leadway by matchiivj CPS data and 
calculating inflows and outflows for the matched obeervatlon?. (Edc, 1984) . 
Hcwever, fdr nail oocqpations such as nany in allied he^th, these estimates 
are based on an extmely nail nunber of objervations. This is an area 
%here associations oould do a great deil to iaprwe the data, ihe Forum on 
Allied Health Data, %iith appropriate eoqpert ocnsultants, should give 
attention to this eerious maJofiess in the data. 




- 18 

Conclusions and ItoooBiDendatians 

The cxanittae found that available data for assessing the mjf^ly of 
allied health perscmBl is inadequate, and sugcfests that efforts be made to 
SjifaxNe the data. Ihe oqploynent (dooand) pcpjectiois of B[£ are very 
valuable, an3, tmd in O9njunc±ion %dth other data, are liJoely to be the only 
demand estioates available that are nntiarahle acxoss fields. 

Ihe federal govanmiit has a raqponsibility to nonitor n^a health 
«arkfbrc3e and to infbm participants in the health labor aaxtet, and public 
pdicynakBrs of tnnds and developnents. Ihe wooic of the Bureau of Health 
Professions, the Bureau of labor Statistics, and The center for 

Education Statistics is to be ' <^o^^ and liuuld be built upon, m order 

to ijiirove the data on allied health fields, thft ffTIT^^^W rB^gmimdff V^* 

in Servioaa mnvene an ■'nfaeraaenev task forc» 

fnm thf ftiimma wf Tntrrr ««-*t<«*-<"" nanter 

•len statistics, and other acwneies that collect relevant data on 

the allied Mnrirfotoe. Thla »^»V ftfyinlfl Yff?!l1^ »/m«rt< irirr^tiim 

^ ynminf ftf^ <iyinr»/<nB thft gWlltY 'ft f^* '^m^ ^nfftrm H«ihHff nnUev 

fltrlffim "" ifcers. healt h care managerB. unions, nrosceetivp shidpnt-s. and 

Staff for the task force atould be provided by the HS focal point for 
allied health personnel that is ressnaHided in Ou^iter 5. 




19 - 

Bauder, J. 1983. Hethodology for Ftojecting the Nation's RituxB NUrse 
Raculxanents. institute of Medicine. Januaxy. 

Edc, A. 1984. *VBtf Ooci:(]atiGnal Separation Data Inpccw Estinates of Job 
Replacaenent Needs." Monthly labor Revdaw Vol. 107:3-10. 

Goldstein, H. 1987. ^Anojections of DEoand and SKqpply in Oocqpations. 

Rnpaxed for the Histitute of Medicine, National Acadon/ of Sciencses. 

Hall, R. E. 1978. Job Vacancy Statistics in the ttiited States. National 
Onemlssion on BqplcyBBnt and Unploynent Statistics. Bado^xund paper 
No. 3. May. 

Jaocby, I. 1981. Riysician Manpower: or^lAC and aftexviaxds. Public Health 
Reinrts. Vbl. 96, No. 4:295. JUly^August. 

Mcxithly labor Hevimi. 1987. Vol. 110, No. 9. Septgi±>er 

Southern Regional Education Board. 1978. Tie mfonaation Gap in Allied 
Health MaifXMer. 

U.S. Oongress, Office of Tedviology Assessment. 1985. Denogrsqphic Trends 
and the Scientific and E^ineering Wailcforoe--A Technical ManoranduD 
(Washington, D.C.: U.S. Govemnent Printing Office, aiA-lMH5Er-35, 
Deccnber. ) 

U.S. Oongress, Office of Tachnology Assessment. 1980. Forecasts of 

Riysician Simply «uid Reguirenents. (Washington, D.C. : U.S. Govennent 
printing Office. April. 

U.S. Department of Health, Eduaticn, and Welfare. 19*^^ Ohe Geogr^iiic 
Distribution of NUrses and Riblic Policy. EHEH P plication No. (HRA) 
75-53. May. 

U.S. Department of Health and Kanan Services. 1986. Fifth Report to Ihe 
President and Oongress: On Ihe Status of Health Rersonnel in Ihe 
United States. EHHS Publication No. HRS-PKX>86-1. March 

Yett, D. £. 1975. An Ecsncnic Analysis of the NUrae Shortage. D.C. Heath 
wd Oon()any> Lndngtcn, Mass. 





Chapter 1 described 10 aUied health fielcto. People vorkiiiL, in these 
fields have seen tb^^x xples evolve in respo n s e to ficzoes such as 
denographic change, .11 sense patterns, financing tzenSs and structural 
changes in the delivecy systan, and terhnologioal developnent. Ihis 
chapter eocmines these and other focoes to estaUiih a context for Chapter 
4 uhich iHenifTsnff denand and supply in individual allied health fields. 
Before looidng individually at each of the envixtmental pcessures that 
predicticra of the future nist take into aoocunt, the interaction of 
several foroes in one allied health field— reiq)ixatOEy ttmap/^is 

Ihe HGvenent of Respiratory Iherapy into the tLm: 
The Role of Interactive Fbroes 

HhB a p v em a i t of respiratory therapy into the hone is an exanple of how 
sevual cnvironnafital fbroes acting together may inpact on the evolution of 
a health service. These forces my faring about a shift in worksite and 
affect practitioners' independenoe, earnings, and educational requironents. 

As Kxth other alliad health services some respiratory therapy 
services have shifted from hoepital-based to hone-4xu8ed delivery. Althcxig^ 
req;>iratory therapists have long provided ODcygen to patients at heme, only 
recently have technblogioally advanced life stcport aysteaDs, such as 
nechanical ventilators, been %ddely used in the home. Severel forces 
operating together asy accelerate the trend toward home delivery of 
respiratory therapy. Ihese include demographic change and technological 
chi^ige. Health care financing policies are anbivalent in their effect. 

Pfflnoorachic Qiar*je As of 1984, approdntely 28 laillion Americans, 11.9 
percent of the population, vera 65 or older, and the 75 plus gmqp is now 
the fastest grwing age segment of the population (Office of Disease 
Kevention and Health Fktnotion, ISdV) . Ihis aging of the population can 
be viewed in terms of its relationship to disease prsvalmoe; as the 
population ages, chronic iHsiviffm grw more prevalent. It is estimated 
that over 3 million Medicare patients suffer fktn chronic obstructive 
pulmonary ^^a^g^^g such as oiphyMma, chronic bronchitis, and asthma. 


- 2 - 

Alaost a quarter of a yillion others axperienoe fareathijig difficulties for 
reasons other than puljnonary disMse, such as qpinal oord injuries. As 
■an/ of these ocnditions progress, respiratory therapy tMyxmrn necessary. 

TedmoloffW i rtwnge Several innovations in technology make hcneHbased 
respiratosy care feasible and wan acoeptable to patients. For instance, 
eq^i^pment has beocDB nailer. Bobb adc x ^ r i tt x i e ea c tt^o ontrolled ventilators 
and suction aachines are oonpact cnou;|h to be ansited on %teelchair8 or 
qpecially aade carts, giving pacple a aaasure of aabllity. 

HWiltfl Qon Financ e policies aivironDental forces are not always 
expansicxiary. Health-care financing policies, including pressures to cut 
health care costs, Aiel the aove to heme care. On the other hand, 
policies wy be used to curtail an eagansion of hone care that is made 
possible by xmi technologies. 

Medicare's prospective payment system (PBS) is stiinalating th^ need 
for respiratory therapists outside the hoqpital. WS gives ho^ltals a 
strong incentive to discharge all patients as quickly as possible, thereby 
reducing the hoqpitals' costs. Rilnonary patients, though veil enou^ to 
be discharged, are often in need of care at heme. Medicare, however, does 
not reifl)bur»e the hcne care services of reepiratory there^ists on a per 
visit basis. Rather, the cost of their services nay be included as an 
administrative eoQ«ise fay agencies providing hone care services, only six 
percant of home health agencies retain a respiratory thrrapist. The rest 
occasionally consult %dth tlierapists, con tr act vith durable medical 
eguiffloent services, or arrange short-term training courses for their 
nurses assigned to pulmonary patients. Respiratory therapists enployed by 
siqppliers of ocygen and other eqaiinent are rai2±ur8ed by Medicare's 
durable eguipottnt belief it. In a 21-6tate survey, the American Association 
For Re^iratory care (AARC) found that Medicare and Medicaid vere paying 
more than $270,000 per year per ventilator-assisted hospital patient* 
A?RC estimates that the cost for egoivalent care in the home vould be 
$21,000 per year. R iith ermore, it was estimated that over 2,000 duronic 
ventilator-dependent hospital patients %iere veil enough to be cared for at 
home (Gilmartin and Mate, 1986) • The Health Care Financing Administration 
argues however, that e^qpanding Medicare ooverage to include hone-based 
re^iratocy care could very likely serve to inaease Madicare costs since 
it vould be difficult to limit specialized care to these pereons %riho truly 
need it (Health care Financing Administration, 1986) . 

In simi, financing policy has both provided an iipetus fdr respiratory 
heme care as veil as inpeded its growth. Lqproved t^hnolog^t' (spurn:! on 
by the availability of financing) has made reepiratory home carp feasible, 
and the incxea^^ing nunter of elederly in the population has hei^(htened 
danand for such a service. The social value placed on indepmdent living 


« - 7S 

has incxeased the marketability of deliving of eervioes in the hone and 
has placed panessure cn policy nakera to expand insurancse benefits to 
include hane-deiivBrad care. 

The rvoainder of the chapter eseamines a nunber of farces Individually 
to see hov each inpincm cn the doDand and sqpply of allied health 
personnel and to aqphb. m hov an understanding of these forces can help 
local decision aaloei-B interpret change in their own environnent. 

FuL'Obb that Drive the Denand for 
Allied Health X^nctiticners 

Bcpulati o n Growth and Onogr^iiic Tkends 

Daiiuyia t idc trends provide clues about tdmrxow's health care 
oonsumers and their health care needs. An analysis of changes in the 
oonpositicn and grow«-h of the U.S. papulation shcMs how these translate 
into changes in healtn care needs. 

Bopulation growth is slowing. Ihe Uhited States population increased 
by one percent annually between 1972 and 1986, but the Bureau of the 
Oensus ptpjects growth of only 0.8 percent yearly to 200C. The rate of 
grcMth %dll not be unifom among age, race, or eitnnic groups, as eftiown in 
Table 3.1 based on the moderate projections by the Bureau of tiw Oeraus 
(FUlerton, 1987) . Minority races %dll grow faster than vhitas; the 
nukiber of children and youths (with exception of hi^i-school youths) will 
decline; the working-age population %dll grow twice as fast as the total 
population; and the nuober of peqple of retirement age will increase with 
the greatest rate of increase oooiring among persors 85 or older. 

Ihe Elderly Between 1940 and 1984 the naiier of people aged 65 and over 
■ore than tripled, growing fran 9 to 28 million, and is anticipated to 
grew to 35 million, 13 peroent of the population, by 2000. Wiile 
increases in the nuniser and proportion of individuals over 65 Yonb been 
considerable, a faster rate of growth is evident in the very old segment 
of the popilation. In 1950 there iwre just 600,000 people over 85; by the 
year 2000 that nuoDber is es^ected to have increased nearly 8 fbld. 

As the nunber of «lderly inornaTnc, the denand for allied health 
practioners in a variety of fields will rise accordingly. About 17 percent 
of orcupational therq;>ists' total practice in 1982 was in providing 
service to the elderly in nursing hones and acute care hoBpitals. 
Audiologists now qpend one-third of their tins with older persom 
(National institute on Aging, 1987) . Using strai^^ line projectiora and 
assuming that he mix and ratio of personnel to patients will be the same 
in the year 2020 as today, the National Institute on Aging estisates that 
twice as many ooa;()ational and physical therq;>iats %dll be needed in 2020 
as are available today. Forty percent nore audiologists will be required 
to maintain service at its current level (National institute on Aaira, 
1987}. ^ 


- 4 - 

TABLE 3.1: U.S. Papulation by Racse and Age, 1986 and projectad 2000. 





1986 2000 




















Asian & Otter 

















































85 and older 






SOURCE: FUllerton, H. N., Jr. 1987. Labor Faroe nnpjections: 
Monthly labor Review. Vol. 110, No. 9 (Septenber) . 


Qiiid^Tgn Between 1980 and 1984, the nunber of school age childiw fell by 
2.5 million. During that same period, however, the under five population rose 
9 percent to 17.8 million. Ihis was the largest under five population since 
1968, %Aien it vas 17.9 million. Ihe Bureau of the Oansus collects there to be 
fe^er children under five (16.9 million) by the year 2000, and the nunt>er of 
ciiildren as a whole (under 17 yeeas old) will fall fktxn 67.1 million in 1986 
to 65.7 Tvillion in 2000 (FUllerton, 1987) . 



Qilldnn an) adults use heedth servioes differently. Children have 
less noed of aoite care servioes and have fewer hospital days (National 
Center for Health Statistics, 1986) . A raducrticn in the runfcer of 
children in the pcrAilation does not affect dnand for all allied health 
practiticners. Fbr those practiticners eoployed fay schools 
(speech-language pathologists fbr mxattpLm) , the naober of children in the 
pcpulaticn iiqpacts noticably on donand. For practiticners fbcused on 
acute care, the iiqpact, if any, is only sli^. Children are also major 
users of disease prevention servioes, seme of lAiich enploy allied health 
practitio n ers— dental hygimists in dental caries prevention for exanple. 
Far practitioners in var&y allied health fields, children repc^ssit only a 
oaall portion of ttmix practice. 

The iaplications tear allied health practioners of the predicted drop 
in the nunbers of children in the population mist be balanoed against the 
effect of disease preven t ion efforts and the vigor %iith %4ilch such efforts 
are being made. 

The desnand for those allied health personnel %Ak> are most central to 
child health service s — dsi t al faygienists, speech-language pathologists, 
and audiologists, for exaqple-^wlii depend to a great e3ctent on pGblic 
investjnent decisions that are often made at the local level. Local funds 
are the sole source of support for health education p r ograms in 75 percent 
of all school districts. About 20 percent of school health education 
prograns receive state ftmding, and only 3 p e rcen t receive fedenl, 
private, or apecial fUnds for health education p rogr a m s . (Office of 
Disease Rnevention and Health Rxnotion, 1987) . 

Minorities One out nf five persons in the U.S. in 1986 vas a neoDber of a 
minority groqp. Blades, the largest grotp, nunbering 29.4 million, 
constituted 12.2 percent of the total population in 1986. By 2000, 35.1 
million blades will represent 13.1 percent of the population. The nunber 
of Hiqpanics is rising even more sharply. Hiqpsoiics totaled 9.1 million 
in 1970, 18.5 million in 1986, and are esqpected to reach 30.3 
million— ever 11 percent of the population— in 2000. The number of 
Asiaiyiteific Islanders in the Uhited States is also growing nqpidly. 
Betiiieen 1970 and 1980 this population gro^ 120 percent to 3.7 million. By 
2000 it %dll be 11.6 million (FUllerton, 1967) . 

The prevalence of ecne dlseasfts is higher among minorities than among 
%hites. Diabetes, fbr exanple is far more prevalent among blacks than 
among %Aiites, aund the incidenoe rate for cancer in 1983 was hic(hest among 
black males. Among native Anericans, cirrhosis, pneumonia, and diabetes 
are imre oonmon than among idhites, and the prevalence of diabetes among 
Hexlcan Americans is nearly twice that among irihites. (Office of Disease 
Kevention and Health nncootion, 1987) . 

The changing proportion of the minority population and the hig|her 
prevalenoe of some dlsnasfts among the \arious groqps in that population 
may ispact on demand for services as health care needs change. However, 
factors such as financial and geogrephic acoess barriers also influenoe 

- 6 - 

danand for health asrs MKvioes, hoiNe«;er, and hea7.tii care needs do not 
always translate into dnisnd for servioes. Mimritles, vitw are more 
likely than %i*iitee to lack health care insuraroe, ccnslsttaiUy report 
havii^ •greater difficulty than lAiites 1^ oedning aooess to medical care. 
IWenty-six penant of His|panloB have no mriicaO. ooverage oanfared vlth 9 
percent of vhites and 18 percent of blac^^ (Otfion of Disease Preventicsn 
and Health Prcnoticn, 1987) . 

These dif terena« be tw ee n %Adtes and minori lies in their aosess to 
health care are refleut^ in health care utilization rates. IVaity 
percent of blades and 19 psroent of Hiopanlcs, ccapared with 13 percent of 
whites, indicate they have no usual maax» of nadioJ. caie. 13ie 
percentage of people 4-16 yaars old who h^d nnrver reoe.lved d«ntal care 
between 1978 and 1980 was among MEodcan-Mnericam (30.7) than amcrg 

blades (22.3) or %Ailtes (r.7). Similar^^ he perojntage of individuals 
with no physician oar»-«ct was hi^ier among Mexican Americans (33.1) thrn 
aaong other Hispanics (23.9), blacKS (23.8), or whites (20.4^^ (0£ toe of 
Disease Rneventicn and Health Rcnoticn, 1987) . 

Ohe expected increase in minori^ pqpulatioi grw^ to the year 20C0 
could have an iopact on need for the services of allied health 
piactiticners. For these needs to translate into effective demand, 
however, acne bai .-iers to care loist be eliminated. 

Disease Patterns 

There are t»ro changes in the disease patterns within the tftiited 
State? that deserve spucial nLcenticn because of their potential ia^ act on 
allied health perscnnel. First, there is the growing cpidadc of the 
acguireu imuno deficiency syndixxe (AIDS) . Second, whereis infectious 
dlBftftfys such as influenza, ■nallpoK, and tuberculosis were the leading 
caur;es of Jeath at the t>xm of the oenturyi chronic diseases predcoiinate 

AoqLired ir^^jr? flgf jgia^ evndraiie AIDS is a notable and uneaqiected 
ejooer ticn to the trand of dediniri^ death rates from infectic ; diraase. 
Ab of 1987, an estimated 1.5 million Americans were infected with the HIV 
virus. AIDS cases in the U.S. rose firm 183 in 1981 to nearly o^ooo by 
the middle of 1987. Over 75 percent of persons diagnosed with AIDS did 
%rLthin two years of ttie diagnoGl's. 

Aa the disease spreads, ;jrid if the life expectancy of infected 
indivKluals lengthens, the health care systen %fill be inz^asingly taxed. 
In 198'^, AIDS caused 23,000 hospitalizations, an incKsase irm the 
estimated 10,000 of the year be^:bce. Ihe average length tf . cay for AIDS 
was more t» a double the overall average of 6.5 days (Dnfford, 1987) . 
Ihe federal gcraraent astioRt^ that it will spend one bllliai dollars on 
AIDS in fiscal year 1988, with 40 percent of that going to patiert cere. 
An estimated $8 hill' ,i to $16 billion in ctu-ect medical care eoqiendituzes 
is esUnated for 1991 (Healt: \'tescL£oes and Servioes Administ.acion, 




BstiiEAtlng the lirtmct of AIDS en the dtanand for allied heath 
perscmel Is fTai^lht with unoertainties. Greater praclsicn in oBtimting 
needs and %K2rkloads vUl ocne tram a better understanding of scne key 
deteminants. I)pideDd61ogists can only rouglhly estinata the nuDober of 
indivlAials currertly infected as veil as those «ho will develop tl^ 
fliUH^l^^yn synptcns of tiib disease. 

HhB disease sanifests itself in wany toots and treatinent patterns 
vary. Ihe progression of the disease often resenbles chronic mnpRses of 
old age (dementia and %»sting, for exanple) • AIDS patients tiieref ore need 
MDe of the sane services as the elderly and cjqpete for ecaroe resouroes 
each as ddlled nursing care and hone health service (Health Rascurrses and 
Services AAninistraticn, 1988) . Use of acute care facilities relative to 
odmunl^ settixdgs nw v& among localities. Ihe introduction of rma 
preventive, diagnostic and treatieent nodali sir/ alter the nix of 
personnel and eettings of oere in vays that are now difficult to predict. 
Methods of financing care nay also {day a role in detemining the type and 
focus of care. 

Some allied health fields already play a najot role in addressing 
AIDS; for othere, their role is still emerging. Clinical laboretory 
persomel are not only conducting the tests used to detect the vims that 
causes the disease, but are facing a heavier vorklofld generated by ^he 
secondary inf ectic that AIDS patients acquire. Occupational therapists 
are helping AIDS patients learn how to conserve their energy, and 
reepin±ory the^ists provide carr to patients vho develop lung 
infections. A host of counselors are energing to asFist patimts during 
the various stages of the disease. 

ToB ccnalttee noted grudng oonoem abaxt the inpact of AIDS on the 
supply as veil as the donand of allied health practitionere. Sodd 
educatore fear that potential allied health students nay be dlBfawVd by 
the perceived increased risk of e)qpo6ure to the disease. To date, there 
has been ncAihing beyond anecdotal evidence to indicate that this is a 
serious factor in career choice. 

Qironic Diseases Chronic conditions are the nost prevsdent health 
problem for the elderly, and the proportion of elderly in the porulation 
is inaceasing. Hore four out of five persons 65 and over have at 
least one chronic ccrdition and itultiple oondj^icms are ccmnonplace among 
older persons (U.S. iSenr.te Special Oonmittee on Aging, 1987) . 

Ihe dflRDUid fdr allied health practitionere nay be inffluenoed both by 
efforts to curtail the incidence of chronic disease, and by nedical 
su G o es es in treating cfcronic oonditiaji. For ec^aople, sent: allied health 
fields are directly affected by w^xtespraad efforts to reduce risk f actore 
for cardiovascular diseasa. Qinical laboratory personnel are conducting 
ncxra blorl tests and dieticians are providing ioore counseling in an effort 
to deternine and control cholesterol levels. lirreaied ntes of survival 
in cases of stroke and heart attadcs nay nean increased donand for health 
care since the ^^jcrlty rf patients do not nake a full recovery (OiTf ice of 



- 8 - 

Disease Prevention and Haalth I^nooticn 1987) . Of the nearly tMo sdllion 
stroke patients in the U.^. , 40 peroent require special sen^ioas and 10 
percent require total oare. Rasults £ran the ftandnjham Study indicate 
at 31 percent of stroke survivora needed assistance in self-care and 2.7 
percent: ra^uired help in aniMlatlcxi iten examined an average of 7 years 
after their stroke (Office of Disease Knsvention and Health I^anotion, 

Fkxnomic Growth 

Ohe growth of the econooy as a vhole tells how nich inoone will be 
generated, and how this %dll affect gcvexniient ^pending and the incoac 
available for families to qpend en health care as wall as other kinds of 
oonsunption and savings. 

Ihere are many uncertainties involved in projecting ecxnondc 
changes. Ihey range fnn policies that will be adopted on taxes, 
gcivernnent c4)enditurBS, fr eign trade, events such^as wis and 
revolxiticm, to scientific disoG^«ries affecting technology, and even the 
weather that luy kill crops or czeate disasters. MsOdng a projection 
entails making assunpticra as to how each of these vlll affect eoonondc 
ciiange. Htm Bureau of Ubor Statistics, vhose enploynfint projections we 
use, details a long list of assunpticns and calailatfts a hig^, a lew, and 
a noderate projection to illustrate that there is a range of error around 
any projection, and t^> dascribe the sensitivitiy of the projections to 
these variables. (Data for the fdlowing discussion of the ELS economic 
projections are founc* in Saunders, 1987) . 

Personal inoome affects all kinds of expenditures, including health 
care qpending, in many iMrys. For instance, it irJ^luenoes what consumers 
are willing to spend on health ixmiranoe. Ihis sector of the econony also 
contributes cOxut a quarter of national health care eoqaenditures throig^ 
dira:t, out-^f-pocket payment for services (Health Care Finanacing 
Administration, 1987) . Real disposable incxme (in^ ^ after taxes and 
before inflation) is expected to grow by 2.4 percent annoally, less than 
the 2.7 percent in the previous 14 years (low projection, 0.7 percent; 
hi^ 1.9 percent) . Fton ^lis is derived personal oonsunption e>qpendtiures 
on services (of vhich health setvioes are a part) , which are expected to 
grow faster Inan total personal oonsunption e)$)enditures, as it has in the 
past; 3.0 percent, ocnpared to 3.2 percent in 1972-1986. (low 
projection, 2.2 percent; hi^ projectinn, 3.3 percent.) 

Goverraent ^sending is influenced by eoonondc conditions. The BL5 
projects higgler federal gcvemnent spending in their hi^ growth 
projection than in their low growth projection. This is jnjXMTtant for 
health care cnploynenL becaufte ttm federal gcvemnent coccunts fbr nearly 
29 percent of national health eoqpenditures. Thr BL6 projects the Madica:^ 
portion of federal heal^ eoqpenditures in constant doT ^rs. The increase 
from 1986 to the 2000 low pr ojec t ion is 30 percent, r ^ to the hi^ 
projection 62 penxnt. Between 1986 and 2000 noderate p r oje ction a 43 



peznnt increase in osqpedituxes is porojected (Saunders, 1987) . These 
differennes oculd have an effect on those allied health poractiticnexs 
%tese erplcymant is isignificantly dependent cn Medicare spending. 

I^iv^ta health insuFanoe, «hicii pe^ over 30 percent of national 
health escpenditures, is affectea by eooncnic oonditicm in sevral ways. 
For instanoe, the size of oocponite profits can affect the richness of the 
benefit packages and health insurance that Mployers offer cnployees. 
FUrthemore, the noter of people covered by private insurance depenis, In 
part on the unoiployiMnt rate, which in turn depends on econucdc 
conditions. Because unenplcyed people ofton lack health iisuranoe, in 
tines of hi<fi unenploynent deoand for noKWsential (and acne C6se:±ial) 
care is reduced, and health care aployenent viU be redund too. 

Structure of the Health Chrs Industry 

The structure and organization of health services is constantly 
evolving in response to such forces as the availability of money and 
aanpcMer, regulation, consumer demand, financial incentives, and 
tecinology. Major changes of recent decades include the growth of nulti- 
hospital systeBis and investoa^owned health care providers, the growth of 
■anaged care, and the movanent of care tvca inpatient service into 
outpatient departments, physicians' offices and spedjelize^ fkeestanding 
centers. Figure 1 illustrates the decline in the hospit^ as the prime 
cnploynent site for the health industry. Ohis dediLne r fleets a 
structural change--hoGpital's fall fircm primacy in haalth care provision. 

Strwtural changes isa^ or may not iapact on health services delivery 
and the demand for health care workers. Changes in the location ox a 
service may represent only a change in worteite for allied health 
personnel, without altering/ the ruBober of persons cnployed. For exanple, 
hoepital admission tasting is today often ^jone on an outpatient basis and 
unless there is a change in the volume of tests performed, there is no 
numerical significance for cnployment. Although structural changes may 
not affect demand, they could have an effect on education reguiremnts and 
regulation. Rractitiorers may need new levels or arrays of sldlls in the 
new settings, and new guedity .ssncems may onerge resulting in changes in 

Other changes in the structure of the health care industry have 
considerable inplications for demand for allied health practitioners. For 
exanple, as patients' length of stay in a hoqpital becomes shorter, the 
need for home care increases and more pract- .tioners nay be needed. To 
detennine whether a dt^ar^j fjn the location of care has inplicaticra for 
denand, one must ask wnether each allied health field used in the 
txadit^fonal location is lilody to be used ir the naw setting, and whether 
VDlune of service and productivity will cfjange? 

- 10 - 

Figure 1 

Hoqpital BqployDent as a Fercent of Haalth Industzy Bi|)loyiDent: 

Oedendar Yaars 1SS5-86 


^ i I I I I I ■ i I i ! r i I i I ! i I I I I 

t»j5 1966 1971 1974 1977 1900 1983 1966 

Source: U.S. Bureau of Labor Statistics: Data from the establishment survey. 

Eliploynent and Earnings. Washington. U.S. Goverrrent Printing Office, 
varicas issues in 1986 and 1987. Fran Health Care Financing Administrauon, 
Division of National Cost Estiinates. 1987. National Health E>qpenditure, 
1986-2000. Health Caure Financing Review. Vol. 8, No. 4 (Summer) : 5-36. 


The grcwth of HMDs has to date had no real ixpact on allied health 
cnploynant. A 1987 survey of cdliixl health cqplaynent in 56 HCs 
(Including ataff , grxp, and independlent peactior association (m) 
models) across the oounby, found that flnplcyaent for most allied health 
fields is not substantial. For exanple, 22 ncs oqployed a total of 110 
BBdical technologists; 26 HM3b cnployed 42 nutritionists and 13 »D6 
enployad 34 physical thenpists. Reiqcndents did not CMpect to eoplcy 
Idxgrsr nnberB of practioners in the near future (Rulnan et al. , 1987) . 

fomaticn of niltihoepital aystcoB is iqportant to allied health 
eoplc^pent if these systeob staff diffeiently than independent hospitals. 
Studies ocnpdring staffing in different types of hospitals have often 
frcused on CMnership diaracteristios such as public, private, for-profit, 
not-for-profit (see, for exanple, Hatt et al. , 1986; Mjllner and Andes, 
1985) . Little is known daout the dif ferenoes in staffing between 
independent and nulti-institutional facilities. 

Ihe Bureau of Labor Statistics (BIS) projects eoployment in the 
heal'A care industry to the year 2000 (Personidc, 1987) . (See Appendix V 
for a detailed eiscussion of these projections. ) The projections take 
into account acne structural changes discussed in this section. Notably, 
the BLS forsees hoqpitals increasing cnplcynent deqpite the shift to 
outpatient care. Ihis is largrly due to the eoqpected increase in elderly 
people and advances in tedmologies. Table 3.2 shows actual cnployinent in 
1986 in five health care settings, and the BIS projections to 2C00. 
Oitpatioit facilities with an annual growth rate of 4.6 peroent «re 
o^ected to show the hicfhest growth rate aol ranks as the second fastest 
growing industry in the eoonony in terns of fvployment But, because the 
private ho^ital sector is so such larger, its one peroent per annum 
increase will add aLoost as many jobs as the 4.6 peroent growth of the 
outpatient setting. Ihe second fastest growing sector^ffioes of health 
practitioners, reflects the growth of such activities as physiciars' 
office labs, office surgeiy, and independent allied health practices. 
Nursing hones will also eo^ience rapid growth as the aged population 
grows aM early discharge from hoepitals increases deaooand for nursing hcne 
care. Ihus, an additional 800,000 jobs will be generated by nursing and 
personal care homes by the year 2000. 

Health care Financing 

Health care esqpenditures in the U.S. are rising. In 19B6 an average 
of $1,837 per person was qpent on health care f^ar a totaJ, of $458 
billion. Ihis constitutes 10.9 percent of the GUP, up trm 10.3 peroent 
in 1984 and 5.9 peroent in 1965. Ihe Health care Financing Administration 
projects health care eoqpenditures in 2000 of $1.5 trillion-of irihich the 
federal go vei nu m it will pay alnost one third, private insurance 30 
peroent, and patients will pay one quarter (Health Care rijiancing 
Adninistration, 1987) . As health care payers look to the fUtxire, the 
pict ure is one of ir.creasing costs as the population ages and scimtif ic 
advances aiake care ever loore oonplex. 


- 12 

TABEE 3.2; Vaga and Salary Wocker Efecaoymant In Hea7/ch Sexvioes. 
1986 Actual and 2000 Rejected. 

Annual increase 

Ss^m im 2m (rxxcer± \ 

Health Services 7,599 10,844 2.6 

axcluding Faderzd 

Tbtal Rdvata 

^th Seri^ioes 6,551 9,774 2.9 

Offices of Rxysiciane, 
Oencists and other 

Health FKactiticners 1,672 3,061 4.4 

MUrsimj and Personal 
Care IF^icilities 1,250 2,097 3.8 

Private hospitals 3,038 3,513 l.O 

State and local 

Hospitals 1,048 1,070 0.2 

Cut^tient J acilities 591 1,103 4.6 

and health sexvioes, 
not «l8uhare cited 

SOURCE: Valerie A. PbrscniX, 1987 3ctiGns 2000: Industry Output 
and Biploynvit lhrouc|h the land of the Century. 
Monthly Labor Review, 1987. Vol. 110, No. 9(Septenter' :40-44; 
Bureau of Labor Statistics. 

ERIC • 8S 

- 13 - 

It is difficult to overstate the effect that f iiiancing policy has on 
the deoanl for allied health perscmsl. Tkfo types of inpact on oopploycent 
should be hi^i^ited. 

Fizst, financing incentives can chuige the My a health care provider 
views aUi^d health services, ftiereas sou services, such as laboratory, 
%iere considered xevenie pcoducing prior to prapectlve pricing, th^ are 
now perceived as a cost elcnent in the health care product and ripe for 
mnacymPT i t efforts to maarmAz%. Alternatively, the wy care is 
xeinbursed can create inomtives ftar expansion of a service, to \itdch 
allied health vorken contribute. For exanple, the ability of a hoepital 
to enter the sports ndicine aarlcet %dll depend cn its ability to attract 
physical therapists. 

Second, financing policy also affects the ability of indiv^jdual 
allied health practitioiriera to proqper in the health care narket. At 
issue here are fee-for-service rei]±urBenient and direct access to patients 
%dthout physician referral. Tied to these issues are a set of regulatory 
concerns, such as scope of practice and sq)ervision by other health 
professions in licensure laws. Respiratory therq;>ist8 are seeking to gain 
iff: ect Medicare reiaixirsenent for bene services, so they can move fron 
oQMsidereticn as heme health agency overheed to aarteting their own 
services, not unlike occupational and physical thersqpists. Likewise, 
dental hygienists are seeking to gain independence trm dentists in their 
dbility to bill for services, a norve rdq|uiring both licensure and 
reinbtaseDBnt aoconnod&tion. 

Perhaps the nost dramatic exaBople of the iaixxrtanoe of financing in 
generating demand for services and personnel is the spr^ of third party 
reiaiwrsiaaBBnt in the 1960s \itddti generated increased demand for services, 
an era of hospital building and technology adcption, and rising enployaient 
for health care pmsonnel. Mcsre recently, th^ federal govemnent has 
established c cost oontaiiment aeasure, the prospective payment system 
(VPS) , uhich shifts the risk of the cost to the pcovider. 

A number of observere have emmined the Initial iapact of FPS on 
ho^ital operations. LBnct):i of hospital stay decreased at a fhster rate 
than hact been ocouring previously (tiiere was a slig^ qptum in ..986, 
however) , and occupancy has averaged only 66.6 percent since 1983. Ihe 
proportion of petisnL^ %/ith ooni>leK prablaB has incxeased (ProBpec ive 
n^ment Aewfltiiiniit. amdaa'jon, 1987) . Staffing has be^m altered as 
hoqpitals adapt to these changes. Hoqpital oijplcyBient, ^tdch ^ i been 
increasing at a rate of 4.9 percent per year in the six yiiara isfora FPS, 
decreased in 1984 and 1985. (2.1 percent and 1.8 peromt, rupectively , ) 
and increased only sli^jhtly (0.4 percent) in 1986 (Kospective R^akdnt 
Assesanent Qanmission, 1987) . Fl^rther analysis of staffing irtiaws that the 
use of part-tiam eqployees incrused and for sany allied health fields 
there was a ^ft to hi^^ level «qplcyMS. It is not clear whether the 
Bonm to hi^^ier skill levels reflects the needs of sicker patients or a 
perception that a ahcxre hig^y educatec^ cq;>loyee is a aore cost-effective 
eqployee. ihe tfiift to part-tiaie sta^tthg could be a cost oontainnent 
effort as well as c ao^ to sake flexible staffing easier, for some 



14 - 

allied health fields it nay reflect difficulty in hiring full-tine staff. 
Or it nay signify policies designed to ndnimize the oost of onplcyee 

The Bureau of Health Fxof essicns asked the Jtanerican Hexpital 
Association to report staffing changr« since the introduction of HS. The 
following general txends vers found: 

o increassd ophasis cn productivity 

o hei^^itened dmnd for enployees «ho can %ork in acre than one 
fUncticnal area, thus decxeased interest in professicnal 
Gzedentialing that restricts scope of practice 

o incaneased use of part-tiae enplcyees, contract sendees, and 
float pools 

o inczoased oonpetition anong professionals 
o replaooDBnt of personnel toy capital 
o fewer oanagenent positions 

o increased retraining and cross-training of personnel (American 
Hospital Association, 1985) . 

A floall study of 13 Riiladelphia hospitals in 1985 provides insic^ht 
into pexBomel strategies cf institutions adjusting to nPS« Most of the 
hospitals surv^^ had cut their labor fotce throu^ ottrxtion— priiiarily 
in the nhks of lees-skilled patient care esployees (Appelhaum and 
Granrose, 1986). 

More recent studies of the ispact of R6 on hospitals sugt^^est that 
the downward trend in staffing has turned around. A 1987 national survey 
of laboratories found that after Aarp post-RPS staff and budget cuts, 
test VDlune is ip, budgets are bigger and staff reductions are altating. 
In 1986 only 16 percent of Idbs nported staff increases. A year later 31 
percent vere reporting staff incxeeses (Gore, 1987) . 

Another aqpect of health care financing— nandated benefits— wy also 
influence utilisation. States sandate insurance oo v erage to inprove 
access to servioes. Ih the pest two decades, 645 aandatad oo v e r age bills 
Iiave been passed by states (Soendlen, 1987) • currently, coverage is 
nandated for phyeical tiMrapists in two states, and speech and hearing 
therapists in four states (Scandlen and larsen, 1987) ; some states nandate 
co v erage of all licensed health practitioners. 




TBchnological Change 

The dizBcticn of technological change and its iapact en allied health 
eqploynient are difficult to piredict. Seme changes in health caxe 
financing and the stxxicture of the delivery eystem suggest litely future 
directiora: health csre aanag^erB appear to be int^'orested in technologies 
that %dll iiqpcove productivity and lower costs, and technologies that 
enable pcosdders to establidi organizatiGra that fill a qpecial BEuicet 
niche are also liJcely to be purchased. 

Tachnblogical change is not only reactive (to factors such as 
financial incentives) but prapective as %iell, it drives t!ie ^pe of care 
provided by delivery systons. For instance; the technology of renal 
dialysis drove the cxeaticn of dialysis oentexs and pcdctitioners \tyj 
^ecialize in treating patients %dth end-stage renal disease. 
I^mologies also drive the crganizatiGn of delivery systsoB. Electronic 
telemetry eqaipnent, for exaople, enables patients to be treated in 
non-^tradxtional settings such jb satellite facilities, homes, and 
vdiides. Hew technologies yet to come will influence allied health 
CBploynent is of course not known. Seymour Berry, professor of medicine 
at Georgetown Oiiversi^ and former director of the Kational Oenter for 
HealtU care Technology described tiie following advances at the camoittae's 
VDrioBhop in April 19P7: 

— Autcnaticn in clinical laboratories will pr o g r e s s, decreasing the 
conplexity of tasks and increasing productivity. It is antiicipated that 
the only category of lab personnel that may be replaced by cxmputers is 
the least trained. Ohe more hi^y-trained individuals may actually be in 
greater demand as ocqputers are added to the laboratory. 

— 0GB{ute3>based technologies will be used increasingly, e^)ecially for 
clinical decision-making, administration, medical records keeping, and 
patient mcnitoring. 

Gene J.C and mcnoclonal antibody technologies will generate new 
diagnostic tests. Many monoclonal antibody-baaed diagnostic tests %dll be 
self-eiministeLiad in the future, and new test reagents replace more 
labor intensive tests such as culturing. Ihe early diagnusis and 
monitoring of tuDora permitted by these technologies will change treatment 
modes and p rog n oce s for cancers. 

~ Advances in technology will permit more health care to be delivered in 
outpatient settings. Ihe develcpnent of less invat^ive surgical 
technologies will spur outpatient surgery. As new generations of 
laboratory and diai^iostic imaging equipment become smaller, more 
diagnostic prooedkires will be performed in physicians offices and other 
ncnhoepital sites. O^her technologies, such as programnable infusion 
pimps for pain medication or chemoOierBpy, will shorten !»apitalization 
and allow for home care of patients. 



- 16 - 

TBchnblogioal change that muerges ttm basic fldenoe and represent 
ra&l advanods in diagnosis and trBatment are likely to be adapted. Die 
effectiveness of tedmolcgies is not elvays initially clear, however, 
henoe there is grcwing interest in technology assesonent. It is also not 
clear how technological chang^^ will iapact en narpower, especially in the 
long xun« 

Hew tecimologies follow various paths, and have differing effects en 
the d^nani for allied health persGnnel. On cxie path, for exanple, the new 
technology initially requires hig^y^-sldlled narrower and is of low 
productivity until it b e omes a xoutine procedure able to be asfiumed by 
lower level staff and perfomad at hi^ vaLiane. Jn warn cases, the test 
nay beocme autcnated. This is a path ^pically taken fay laboratory 
tests. Other technologies say uee perBcmel differently. 

Ihe relationdiip betwesi nanpoMer needs and technological chaa^e 
flixrtuates constantly but is seldcn eo^ored. Baking it difficult tr> 
assess the future with such certainty. Mhile there is scoe xmderstanding 
of the fonses that drive technological change, the effect of the change 
idlied health practitioners has not been adequately resi>arched. 

The Sqpply of Other Health Rnctiticners 

Ite sqpply of other health practiticners— doctors, mrses, dentists- 
influences the donand for allied healti services in several %iays. 

As the supply of physicians OGntimek. to grow at a rapid pace (ever 
50 percent growth is expected between 1980 and 2000) , allied health 
pTB^titicners must ask whether physiciarja idhose practices fail to bring 
them the desired inccme will seeX to take back functions they had 
delegated to allied health practiticners in earlier periods. Riysicians 
%«ider about this too. One surgeon wrote. 

lb abrogate cnr^^s respcnsibility for p ostoperative carr* is 
r et r ogre s sive and tends to return to the period of 200 yoars ago, 
%]hen the surgeon was sijqply a technician. 1 do not believe that only 
the respiratory therapists can understand the controls of the MA2 or 
Bear respiratOTB. Z do not believe that the surgecn who operates 
qpon the intestinal tract tfiould need an enteroitonal therapist to 
take care of the problens in a patient with an ileostcn/. I do not 
believe that the surgeon %tx> perfocns a nastectony should reguire a 
physical thenqpist to assure that the patient has nomal arm noticn 
following this cperation (Jordan, 1985) . 

Sinoe ttm Graduate Medical Bduoation National Advisory ODDmittee 
(GEMEHAC) nade its prediction in the 1970s of a surpliis of 70,000 
physicians by 1990, there has been considerable debate in the literature 



- 17 - 

about whether these nrtiers axe in cxoess of an "optinzd" level end, if 
there ia indeed an myoeus of physicians, %«wt that oould mean for the 
health care system. GD4E1AC ooncauded that non-fhysician provlderB (that 
is, physician assistants, nuxse practitlonerB, and nurse-midwivuc') ney 
substitute for physician services and thus aggravate the physician surplus 
(GEMEIOC, 1980) . Some allied health leaders have been canoemed that this 
conclusion has been generalized inappzqpriately to aU hniaSL field&. 

For physicians to assirae «hat axe xam oonsidered allied health 
services, at least three conditions vMt be satisfied: 

(1) Riysicians oust be willing to once again take on tasks that the 
BBdical pKtfession focvent because these tasks were considered repetitive 
u: unchallenging. 

(2) Riysicians must be ocqpetent to perform the tasks. Miile in theory 
the license of medical doctor (H.D.) permits the physician to perform most 
tasks of allied health practitioners, in many cases thfiir training has not 
prqxursd then to function effectively or productively in the full range of 
services of many of the allied health fields. 

(3) Bayers and managers must be willing to raccqpense the substitution. 
Ihe decision to substitute physician time for the tine of the allied 
health practitioner oust make econcnic sense to the physician or the 
ocganization that anploys the pl^ician. In a physician's office this 
ixplies that physician time is so underutilized that it is preferable that 
a physician do the tasks than an allied health practitioner be paid to do 
then. In an organization like an HO that cnploys physicians, it means 
that physician and allied health salaries are so nearly equal that allied 
health practitioners are not %nrth enploying because of their more limited 
scope of practice and smRtimes moce limited patient appeal. 

Ompetition between physicians and allied health practitioners is 
most likely to occur when allied health practitioners are incxeasing their 
autonony. For exanple, althouc^ offering the same service, physical 
therapists, physicians, and chiropractors in seme sense can be viewed as 
ocnpeting for the first contact with patimts having musculoskeletal pain 
synctons. Ihe American ItijfBieal lhaiapy Association views oanpetition in 
the following lig^: 

MHDbers of the American Fhysical Therapy Association 
are actively seeking legislative moval of the zeguire- 
nent for referral, that is, legislative provision for 
direct aooess to their services, and have suco ee d e d to date 
in 14 states (evaluation with referral is permitted in 
another 22 states) . ihis is an 4 oct towerd independenoe 
in practice that does not put the physical therapist- in 
direct ocnpetition %fith the physician, and say, in fact. 




inczoase referrals to phyBicians in appropriate 
cixcunstanras. This is net to say that oczpetiticn is 
lacddng beiwen physical thenqpists and physicians. Such 
ooqpetitlon as does e)d8t bebi^den these practitioners 
is oaqsetition between their businesses, not between the 
aend^oes that each ptrscxially provides to patients. In 
reoent years, physicians have incxeasingly cnployed 
physical therapists in their businesses and CGB()eti 
directly %dth the busixMsses of self-«q;^Gyed pnysical 
therapists and, in scds instanoes, with thB businesses of 
hoqpitals ^ch have a vari^ of out-patient and 
"^outzeach** physioal theraqpy units (American Riysical 
Iherapy Association, 1987) • 

Medical technologists %to are atteqpting to nove more f oroefully 
into roles as directors of fiiU-servioe laboratories are raising issues 
of **arbitrary barriers** iiiposed by facility accreditation standards. 
Ocnpetition »ay ocne frcn physicians %ho are reportedly ^Ing a greater 
involvenent in the laboratory business, and, to the extent that 
pl^ician office laboratories substitute for other testing sites, the 
use of B gd l ca l assistants and cn-the-jcb trained perecnnel to run office 
laboratory eqioipDent nay be seen as a f onn of physician substitution and 

Anaodotally, there appears to be growing OGnpetition and turf 
dilutes between nurses and allied health personnel. At the ocmnittee's 
public hearing, the Association of Surgical Technologists epcte about 
their oontrcKmny over operating roon turf and whether they or nurses 
%dll perform certain functions. Ihe fixture of nurse-allied health 
practitioner confrontations will in part be determined by the siqpply of 
nurses and whether managers will begin to limit the breadth of nursing 
duties. On the other hand, nursing appears to be moving up the ranks of 
f acul^ leadership into higher levels of decision-making regarding 
Whether nurses or others will perform certain roles. 

Oounterbalancing possible direct ocnpetition ftan physicians due to 
their groiidng mtobers is the positive effect of the volume of wcack 
generated by their increased supply. Mhile utilization management 
techniques are geared to controlling unneoes s aiy use, it is unclear how 
effective these tools will be in reducing the volume of ancillary 
eervioes and how this in turn vill affect allied health enployment. 
Moreover, the continuing lyec tie of malpractice mitigates against 
vigorous efforts to control testing. A far-reaching re sponse to 
physicians protecting themselves against liability by practicing 
defensive medicine does not appear inninent. 



19 - 

Ihe rat ef fec± of the incxBsslng phyBician wfply velc(hs more heavily 
tCMaid Inczeasing than deczBasing the servioes delivered by allied health 
pexBcnnel. Ihat is not to say that turf issues betssen allied health 
po^actiticners and others vill lessen, taut it anpeaxs that demand will not 
be unfavorably affected. 

Fbroes that Drive the Si^ly of Allied 
Health Practitioners 

Ihe discussion thus far in the chapter has focused on f actons driving 
donand for allied health practitioners. In this section, «e turn to 
farces that shape the gqpply of allied health practitioners. 

Ihe U.S. Labor Focoe 

Ihe future availability of iJlied health warkers cannot be divorced 
trm larger trends in the U.S. labor force. Ihe Ubor foroe is growing 
nore slowly than in the past and the participation rates of verious groups 
of people is changing. The labor farce is beocning older, nore fenale, 
and includes more racial and ethnic minorities than in the past (see Table 
3. 3) . (Ihe following discussion of the labor farce is based on data in 
Sounders, 1987). 

Ihe nur^ser of %anen in the labor force will .'increase at more than 
twice the pace the nuBober of men, and women will constitute nearly half 
the labor force in the year 2000. Ihey %dll make vp 63 percent of the 
additicTi^ workers filling new jobs. Ohe nunter of men and wanen of prime 
working age-^that is, between 25 md 54 years old-will be the most 
rsqpidly increasing group, %hile tht. .rnber of younger warkers %rill 
decline. Ihe proportion of warioers of prime working age will Increase 
ttm 67.5 percent in 1986 to 72.6 percent in the year 2000. Ihe ruabLv 
of black warkers will incxease twice as fast as the nunter of white 
workers, Asian workers five times as fast, and Hi^mn^^c workers vare than 
five times as fast. Hiqpanic workers will make up 29 percent of the 
warkers entering the labor market bstween 1986 and 2000; other minority 
gmqps oonbined will make vp another 29 percent. 

Ihe econcny %dll be more dependent i^on women workers (who have 
always been prominent in the allied health professions) and upon minority 



- 20 - 

TntnOs in Oollage EhroIlBfint 

In tte lajGrity of ttm allied health oooqpaticm, gnduation ttm 
fbur^yaar or two^yaar obllaga piuyiaim is the varhara qualify fox 
wi>lc3yn8nt. tia ttoarafbana have to examine txende in hig^ education 
enrolliunts and gnKkiaticns as a first step in agppraiaing the potential 
labor eqpply of allied health p eteci m el, Ihe foUcwinor WMeernnrinl- 
utilizee data fkoa the Omue Boraau'e Current Bcpulaticn Reports and 
data developed by the U.S. Dqpartannt of Bdication's National Center for 
Bdtioation Statistice (Onter fdr Bdi»tion Statietios, 1988; Oenter for 
E±»tion Statistics, 1987; Center for Education Statistics, 1970-1987; 
National Oenter for BAioation Statistics, 1985) . 

The population of college age I B to 24 years— is declining die to 
a dacxease in births tuo decades ago. After peaking in 1981, the 
college-ege population drcpped by ei^ percent by 1986, and is e}qpected 
to oontinue declining throug(h 1996 «hen it vill be 23 percent below the 
1980 peak. The nunber of o6Ilege-«ge people vill then begin to rise, 
and ty the year 2000 vill be six percent above the 1996 lev point but 
still 19 percent lower than 1980, and about 12 percent lower than 1986 
(see Figure 2} . Diis constriction in the flow of new vorkers into the 
litor fame vill affect all ocopations. Itether it vill affect the 
professions end other ooctpetions requiring college eduoaticn as nxh ts 
it vill affect thoee oonyatione not reguiring college education depends 
on ii*iether ooHage attendance drops as nich as doee tiie population. 
College enrblljaents end graduations %dll aaintain their current levels, 
or increase, only if a higher proportion of youths go to college. 

Ihe allied health fields are nriinfifti primrily of vonen. ahere 
are a fev fields— emergency nadical eervioes for exanple— in vhich vomen 
are a Eonall minority; and a fev others, such as respiratory theacapf, in 
vhich the tfiare of mn and %Ki»en in the vorkforce is rouc^hly egual. For 
the most part, however, women predcminate. For this reason, ve focus on 
iranen's college participation rates and on tin trends in vonen's choices 
of fields of stud/. 

Ihe nadser of vomen receiving bachelor degrees increased steadily 
between 1970 and 1986, reaching 502,000 in the latter year (47 percent 
more than in 1970) , as a rising proportion of vomen of college age 
coopleted college. 

Ihe Oenter tor Bdbcation Statistics (CBS) projects a further 
increase in the nmter of vomen earning bachelor degrees, peaJdng at 
512,000 by 1989, fcOloMd by e slov decline through the year 2000 to 
470,000 gnA]atae--ebcut 6 percent belov the 1986 level. Since the 
popolation of o^ege age is expected to be 12 peroent belov the 1986 
level !y thm year 2000, this the projection of vomen graduates assumes 
that the proportion of vomen coepleting college vill centime to 


- 21 - 

TNBLE 3.3: Changes in the lAbar Fteoe befe w a o n 1S86 and 2000 (prajecbed), 
by Age, Sex, and Race. 

Iteovic Ctiangpe 

Pamnt DistrUauticn 









10 A 



55 and amr 




2B^B8}f x^ CUM wvis£^ 










55 and over 





liiita, 16 and over 




Bladk, 16 and over 




Asian and other. 

16 and over 





Hispanic, 16 and over 




SOURCE: Rillerton, H. N. Jr. 1987. labor Foroe Rrojectlcns: 1986-2000. 
Monthly lAbcr Review. Vol. 110, No.9 (Septaiiser) . 


- 22 - 

Sinoa theae CES p rojec t ions \miB ande, that offloe has relaased 
prelimirazy data for 1987 (baaed an a 8ani>le of oollajBS) . lhaee data 
inlicata an inczwaa in tha ludbar of graduates bst^aaen 1986 and 1987 
instead of thr daczeaaa that had been projected, lha preliminary estimate 
of vonsn bachelora degree gra&iatae for 1987 vas 512,000-^tM> percent 
above the 1966 figure instead ctf the crm percent drop projected. Ihis may 
mean that the rising trend in the proportia) of ^nen ocnpleting ooUege 
is oontiming even wre strongly than projected. 

Gradu^itions fJtn pimiaas tt^rt zegaira fewer than four years of study 
incxeased mace rapidly than all other awards granted by institutions of 
hitler oducation from 1975 to 1985. Aasociate degrees incxeased by 26 
percen t . Iteroas the increase in men earning associate degree s was only 
six percent, almost 50 percmt more vomen earned asscciate d e gr e es in 1985 
than had a decade earlier. Other less than four year degree s increased by 
45 percent between 1975 and 1985. 

Ihe nmter of associate degree s auaroed fell between 1985 and 1986 
and is p rojected to continue falling thrcuc(h 1996 ^dhen the nmter of 
graduates will be about 11 percent fewer than in 1985. Ihe Center for 
Bducation Statistics does not mate sex-qpecific projections for associate 
degrees, but if current trends in sen's and women's relative share of 
earned degrees contixue, then ve may e)qpect that the dacr^use in women 
associate degree graduates %dll be less than 11 percent. Ihe nmter of 
associate degree graduates is eaqpected to resume its upward clinDb in 1997^ 
but in the year 2000 will still te eight percent below the 1985 level. 



- 23 - 

ngarm 2 

Qollaci&-^ ftculatlen. »nes IB to 24 Years 
(Actual 1980-1982; Rrojacted 1983-2000) 

m im im im m m m iw m \w m mi m im m m m m m m m 

IMS: IB l^vtaent t/l tmeret, liiriau of Uk Chsus, Currwl finilition l»orti . 'ftfulation Estiiates 
nd PrejKtim,* Strits ^2S. 


- 24 - 

Ihe Center for Bfkcatioi StatistiGs' 1972, 1977, 1982 ani prelimiiBry 
1986 data idKw no trend towaxds inciBased oollege enzx>ll]oent among the 
25-44 year old age group. 

Tkmds in Nonen's Oioioes of Fields of Study 

Ihe pro p or tion of women baocalauraate graduates iytx> chose health 
fields (allied health, health scienoes, and nursing) has increased over 
the past decade and a half, in 1970, sli^fhtly less than five peroent of 
women with the bachelor degree chose tiwse fields. This incroased to 
about 11.5 peroent in 1980, declining to just below U peroent in 1986. 
Thus, at a time %ftien the nadbers ot women bachelor degree gndoates were 
imeasing, the health fields nearly doubled their share of that rising 
total. TbB fields of business and M ana gement, omamication and 
ooDBunioation technologies, nrmiiter scimoes, and engineering, together, 
did ever better. Their ehare of wonen graduates incxeased fron less than 
three peroent in 1970 to more than 32 peroent in I986~a more than 
eleven-fold incxease. Ihe gains in the fields of health, business, and 
ooniiUnication were at the eoqwise of education. Education's share of 
wcmen graduates declined fixn about 36 p eroen t in 1970 to 13 peroent in 
1986, indicating a major change in %aaen's career goals. The fields of 
psychology and social sciences attracted gradually declining shares over 
the 16-year period, falling from 21 peroen t to 14 percent (see Figure 3) . 

Among women earning associate degrees between 1983 and 1985, business 
and management was also the top ranking field, followed by health 
sciences. Fcr men, health sciences was not among the three top-ranking 
fields during these ye^rs. 

Ttencis in the choioe of study area within the health fields provide 
additional Infomaticn for use in appraising the potential labor sqpply of 
allied health personnel. 

lAorsing still aoocunts for almost 60 peroe nt of women's bachelor 
degrees oonferxed in health, although this figure has fallen sli^|htly 
since 1970. (see Figure 4) . Hoqpital and health care administration, once 
the domain of men, has beoome increasingly attractive to women. For 
physical ther^, occupational therapy, and speech-language pathology and 
audidogy, fields that require at least a bachelor degree for entry, the 
nmter of graduates has grown over the years but their relative shares of 
health de g ree s have remained constant. Nursing also dominates the aMazds 
leqioiring less than four years of stud^, aooounting for about 52 percent 
of helath scienoes Auji m i in recent years. 

For some fields, oolleges are not the primary ^xxBors of educational 
pioyiaiuB aocxedited by tihe Ooenittee on Allied Health Bducation and 
Accxeditation (CAHEA) . ftuyxam in radiography^ Hear eooDple, are found 
primarily in hospitals rather than in educational institutions. Hence, 



- 25 - 

^ CES data cited, liiich Incaudas only degpws and awards granted by 
InBtltuticnB of hii^mr eduoaticn, does not enocnisass all allied health 
parogran gradoates. However, the inpact of non^oollege education piuyxai u B 
on the validity of thB trends portrayed by the CES data is marginal. 
Althougih nm-OQllege hct t sci i' s aooounted for 40 percent of all 
CMIQ^'^eccE^ted pmgiaim in 19S6, th^ aooounted for only 33 percent of 
the grwkiatas daring the 1985-^6 aor^knic year. 

Ona of the facbocs influencing career choice is the students' 
p e rc epti on of enployiient opportunities. Ihe Bureau of Labor Statistics 
expects the naber of jobs in scne of the fields that are popular with 
ijonen to grov nore elovly ttmn the allied health fields in the cosdng 
years. Ohese fields iiclude: teaching, peych^ogy, eocial work, and, 
surprisingly, K3st of the business eDoeoutive oooqpations. Accounting and 
nursing are epcpected to grov at rcug^y the eana rate as allied health 
fields. Baploynent in a fev fields, including cxirpitw scienoes, is 
projected to grcv at a faster rate than enploynent in the allied health 
fields. To the extent that these esqpectations affect students' choices of 
careers, the allied health fields nay be able to hold their own or even 
gain a largrer share of wcnen college graduates. Sinoe the nnber of women 
college graduates are projected to ronain close to current levels or 
decline only sliglhtly over the next 12 years, the supply of graduates in 
allied health nay renain close to current levels throu^ the year 2000, 
deqpite the decline in the college-age population. 

Education Financing 

A coDiDonly cited aaxin among allied health leaders relates to the 
position of allied health in the peddng order of health professions 
education programs: ""allied health fields are the last to be funded in 
good times, first to be cut itan resources are reduced. " Ihis statenent 
reflects the iaportanoe of the econondc dinate in «hich hig|her education 
resource allocation takes place and hov decisions about allied education 
rDsourcefl are related to ecme broader financing trends^ Education 
financing, the efficienq^ of education prograns, and hi^^ier education's 
perceived contribution to eociety all iapact on the longevity of allied 
health education ptugiam and ftiture supi>ly of allied health persomel. 

CVarall, national higher education esqpenditures in the past 10 years 
have grown. Between 1973-74 and 1983-64 current fdnds expenditures, 
adjusted for inflation, increased 23 percent fbr public institutions and 
31 percent for private institutions. Mich of that growth cane in the 
Bid-1970s. Mblic college spending in the latter half of the ten-year 
period grew fay only 5 percent, end private collega spending fay 13 percent 
(Oenter fdr B:\xaBtion Statistics, 1986) . 

Ihere vera shifts in rsvenue eouroes between 1973 and 1983. For 
pcblic institutions the federal Aaxe of total revenue ^^nr^f^ fkon 12.8 
percent to 10.5 percent; the state rtiare resained relatively stable. For 
private colleges, the percent of total revenue attributable to federal 
eourcee rose fton ^ to 19.4 percent fay the aid-peidod but dipped to 15.7 



Figure 3 

q>e BelativB Siaiies of Seme Maior Fields of Study 

fBf^ Mr— an V^-minq BaAelOT DBQgBeS 


I 1 I I I I I f i I r I ■ I I • I 

iro in 1172 1173 iff* 1179 irs irr 1971 irs i»o lai ins isbs ik4 ibs isee 

1771 iusiM» aiK llni«Ment/ ^mAtf kvucal EZI taul ieiwecs/ 

taMucatiw md €«|iwriiig HrCiolegy 

CoMurjcat:an TcchnclogiR 

SOUfiCC: Digest pf EducJtion SUtistics, sevtrjl nurt. 




Flgurt 4 




Urn BBlatlve Smit^ of Sa« Srfaetad Ifaalth rt^ltte 


It70 It7l It72 ir3 1174 lt7S lf7S If77 in I07t ISO IMl IIB3 l«3 !«« IMS IMS 

SOuet: finest «( IducatioA SUtisttcs, «veral vurs. 



- 28 - 

pcr o en t by 1983-84. Stata and local anpoxpriaticns vex« relatively low 
and dedinad slightly ewer the ten-yaar period— from 3.2 percent to 2.5 
peroent. Both pidsllc and private institutions that own hoqpltals have 
seen Incxeasing rsvonues fixn their hoq;>ital8— frcn 5.1 percsent to 7.4 
pe roMi t for public colleges, and ttm 8.7 percent to 10.1 peroent for 
private. R-lvate institutions rely aoce heavily on tultlcn than do public 
schools, 39 peroent coqpared to 15 pexoent, but the ocntributicn of 
tuition is incxeasing in both types of schools (Center for Education 
Statistics, 1987). 

Kl*tien^ ttwy team batter than sost arts and sdanoe piuyiaiua in 
gaxneri y external funding, allied health piuyiaiuB are nonetheless 
relatl\ ^ nsMocmsn to acadaida. As federal support has dinini^ied, allied 
health program administraton are pfmuwlHtlr about their place in higher 
education institutions relative to traditional departments such as history 
and mathanatlcs, and to prttfissional ptuyiaiub such as engineering, 
medicine, and businass administration. 

Federal funds stiaulating allied health education piugiam develofinent 
peaJced in 1974 at nearly $30 million and diminished substantially 
thereafter. Nb data are available on aggregate allied health education 
expenditures, but mxh of the cost is borne by state and local govemnent 
mqperOitutB and by tuition support in private institutions. The key 
driving farces behind allied health education financing are state and 
local apprqpriatlons, student demand, and the availability of clinical 
facilities and teaching staff. Allied health education ptuyiaiub are 
vulnerable in each of these areas. (See Chi^iter 5.) 

Although there is variability ancng states in the generosity of 
education funding, cutbacScs often means that allied health programs, 
because they are percnived to be eoqsensive, are especially vulnerable. 
For acne allied health fields this is onmrnnrtwl falling student 
enrollments. Uhlike other l^pes of curricula, allied health education is 
dependent on clinical facilities for teaching resources, and is therefore 
affected by health care financing policy as well as higher education 

State legislators and hi^^ier education officials, faced %iith 
difficult l e eourca allocation declslcns, are sedcing ways to assure 
greater aooountability from collegiate institutions. A Michigan 
aoDttissian on the future of higgler education in that state reconnended 
various measures to attain a "stronger, lamer, more efficient syBtcn" to 
save cn capital and operating costs, ihese me* raxes focus on the reviev 
of "non-core'* and "loiMtegree producing** undergraduate p rogam s , health 
care profession programs, hig^Aoostts programs, and pm^tai a s with excess 
capacity Aie to their gBographic location (McKimey, 1986) . 

State officials are also paying dose attention to the products of 
the higher education atystcn and its ijqpact on local econcnlc developnent. 
Respondents to a 50-8tate survey revealed that formal assesanent of 



- 29 - 

stuEtent and iratitutional perfamanoe is a growing phenaoenon and is 
liJQBly to intamify in tha yaaxs ahead, taong tha broad axxay of 
activitias svaluatad by outoeas iiiiwuni iiii nt ara gradbatas' «B|>layinBnt 
aooerimcaes, thair ovaluatioew of the fidooation they racaaived, «n|>lqyer 
hiring pattaxm and fnanr students' Job parfbmanoa. Gountaibalancing 
thifi job orientation is !4 growing oonoam ^t technically trained 
individaals be cxaativa, have the capacity fbr civic xeeponsibllity, and 
zecjeive a liberal edjoation. Specialized aocxediting bodies fbr the 
nrofeeslom are the targets of aadxxrtation to faster currioila that 
indule general edooation in laaanitias, arts, and the social sciences 
(Bayer et al., 1987). 

ftiile vost allied health prognns raport good initial job capportuni- 
tias far thair gradkiates, this advantnge in outoona assessnent is balanced 
agaixMt the lid»ilitifls of unfilled student epaces, the need for expensive 
eviipamt and hi^ fscul^/student ratios, and an iaage in acme acadendc 
settings as lacking in sdwlarly attiributas. 

Other Ftcoes Influencing Supply 

ttiioM Ite noted eerller that the allied health fields' abilily to 
attract students depends in part c i the attractiveness of allied health 
oooBBtlora relative to other occupations open to vauan. The ease with 
which one will be hired and eoqpected eaminge are both f uoets of the 
perceived attractiveness of an ocoqpation. One fitctor that affects both 
earnings and tha kind of life an occqpation offers Is the extent to tAich 
unions are present and active. 

m iHwny occifiations unicfis are a factor in determining denand and 
siEbly. Denand Is affected coUective bargaining agreements oonoeming 
such issues as the length of the working day, taiks that nay be performed, 
and oon|)enBation. Simply is affected by altered pety, benefits, woiidng 
hours, jobs security, and other factors that make an ocofntion sore or 
lees attractive to wockers. 

m recent years, unions have viewed health care, %rlth its many 
unoocganized warkeis, as a major opportuni^ for expansion. In the past 
the unionization MW utaT t has not had xuch success with health care 
workers. Its limited sucxsess has been In the public sector, and then only 
in some areas of the mtlon. Ihis has recently changed, hmever. Miile 
uiion activity in the private sector as a %h61e declined trm 23 percent 
to 18 percent between 1980 and 1985, wion BBBterdiip among health care 
workers incrv jed by 6 percent to about 20 percent of the health care 
wockforoa (Anuloan Hoapltal Association, 1986). Ih gwal, allied 
heal^ oooqpatlonB appear to be cowered leas fregjsntly fcy 
labar-esmageaent oontracts than are nurses, for exaaple. in podvate 
honitals Ln 23 metropolitan areas, 26 percent of nxrees vwre covered, 
oonpared with betMeen 5 and 12 percent of ooa«)ational, qpeach, and 
Ethical theirqplsts, nadloal record adbninistrators, and dieticians. 
Appctsdmately 20 percent of medical laboratary technicians were covered, 
and 16 percent of radiugia p h a rs (Jteerican Hoepital Association, 1986) . 



- 30 - 

Although unioM hsv* not baooue atijor tectar in nary alll«d haalth 
fields, MTvioe vocloBrs hov* bwone, with aare auooMs, ttm foois of Budi 
union activity. 1h» wing auay fton tte direct •ooncnic consideraticns 
that narsing ^jnicm are inthibiting nay prot^ide aone dues abcut the 
oonoarm of other healtt vockers and suggest what nay be dene to nake 
floploynflnt won uLlxactive • 

Malpraetiae Ti1t.1q*^^T ttm aivply of aUied haalth practiticsm in scne 
fields is also vulnerable to the ispact of na^xractioa litigation. Since 
the late 1960s the lutar of Badlcel Balpractioe dains and the size of 
Jury aMBTte has oonrad. By the nid-MVOs iftysicians in soma states were 
having difficulty pu;;chasing nalpcactioa inuranoe as some insurers 
%dtMratf from the aaikat, and acne pliyBicians oouJ.d not buy insuxanoe at 
ary price. Foe all pv^dm the avenge ovt of insurann inczeased by 
81 peroant between 1982 and 1985 (Health care Financing Adbtiniscration, 
1987b) . HBdpractice litigation zaiaes questions about quality, liability, 
an* other issues. Ihe eoqperitticee of physicians suggests hew the supply 
of soB» allied health practitioners could potentially be affected by 
aalpractioe litigation and insuxanoe. P w ntycne pttoant of re^maents 
to a 1984 aurviy by the Awrican Acadeny of Fteidly Ehysicians reported 
that they had zeetrictad their obstetrics practice because of hic(h premium 
costs. lhirty-£ive percent of respondents to a survey by the American 
Oollege of Obetretricians and (^nooologists said that they had respnnded 
to professional liability risks by altering their practice— often reducing 
or eliminating the dbstetrical conponent, or cutting xtc care for high 
riiik. pregnancies (Healtt and Hooan Services, 1987) . 

The supply of allied health practitio^teni whoee autonony of practice 
is limited is unlikely to be affected by malpractice considaations. 
But for soK<» allied health fields this oculd, in the future, beocne an 
isportant issue. Ihe extent of physician svqpezvision of an allied health 
practitioner's work can determine the practitioners legal 
responsibilities. For sKanple, if a pFiysical therapist is the primary 
manager of a patient, the tiMcapist is reeponsible for assuming that 
appropriate infomned consent procedures are fdlcwed (Banja and Wolf, 
1987) . A case brouc^ against an audidcgist reveals the vulnerability of 
practitioners to na^practioa litigation evm when the possibility of harm 
seems ranote. In this case an audidogist's failure to diagnose deafness 
in a child was claimed to have danaged a child bom siiaseguently to the 
parents who, since it has not been diagnosed, %«re not infomed of the 
inheritability of ttm defect (Suprene Oourt of California, 1982) . 

How the physician Kfply has been affected by nalpractice issues can 
be studied by thoee oonceomi with the ftzture aqpiay of allied health 
pactitioners. If practitioners successfully puifti toward nodes of practice 
in vhich sipervijiion (Hn1n1rt>ec and autonony inczeases, malpractice 
litigation and the cost aC insurance could svmtually oonstxain the aqpply 
of practit'xners willing to endure the stzess of threats of litigation, 
and with the resources to pay high praniuLS. 



- 31 - 

Altacnative nittems far DKV«lq;iiiBnt of 
HMdth Sttrvioes: Ihcm Sovnrios 

It is oby^lcus fzOB Qm dlacuasicn thus far that there axe aany f oiroes 
that aay be iaipacting cn health awrvioes delivery and the danand for and 
ivfply of allied health pazaonel. It ie virtually isixaesible to taJoe all 
the elMHtits of all thoae fbroas into acaoBit ihen trying to enmluate the 
future for ary single allied health field. Ihe ocanittee ooneidered ways 
of blinking of altenwtive aaaunpticna eJxut ttm aajar factara that 
influMXX) MqplcyMnt in tiie health industry. It believes that looking at 
a limited luber of altrr >Btive broad eomarioa is a uaeful tool for 
deciaion aekara trying j evaluate the future of aiacif ic allied health 
prof eeaiona . 

Ihe Bureau of labor Statiatica (EES) mik^ enfaoynent projecticns 
baaed on oacxoeaaranic ftctuis— 'Uadte balanoe, aqplcynent rate, 
productivi^, and overall deaand (aee Appendix V) . Although daoand for 
health acrvioee and allied health practitioners is relatod to 
BBCzoaooncntic growth, there are other foKoea at vcak that nay operate 
independently of the aacxoaocnandc f actars and in acme caaee ovendheln 
theai. Ihua, the ocaaiittee offers three siiple aoenarioe driver, by the 
aingle foroe noet liJoely to determine the aize and directiai of change in 
health caxe aervioas— health care financing. Ikifblding eventa can be 
looked at in the context of theee aoenarioe. Deciaicn-nakers oonoe i neJ 
with balancing aqpply and dmnand can acply the acemrioe in estimating the 
danand aide of the equation. 

Ohe three eoenarioe are driven by health care financing for two 
reascna. First, financing is the major foroe driving technology, the 
structure of the industry, and other determinBsnts of allied health 
danand. And second, health care financing r eepond s , throuc^ public and 
private policy decisions, to other iiqpQrtant inflxMnces such as the 
eoononi/, daDognqphics, diaeaae pattexns, and aocial values. Ihua, 
financing re spo n d a to acaie ijipcrtant detarminanta of danand, and drives 

fiaaiariQ One! Miyed Ifadel 

Ihe mixed model aaauBea a oontinuation of the existing mixture of 
me» A ad s of paymvit. Some aervioea, both irpatioit and outpatient, will be 
paid on a pm e pect ive basis (either capitation, diagnoaia, or acne other 
unit of peyaent) , and aone on a retroepective fee fUr se rvice basis. 
Nithin ttm fee for aarvioe eector, acaie payera will negotiate rates with 
prcviders, vhile sone payers will pay on the basia of custcaary and 
zeasonaible charges. First-dollar coverage will be lees uaual than the use 
of oo-payaanta and daductiblea as utiliration csntebls. 


- 32 - 

Hm pcofxarticn of tbm pqpulation in aanaged care rystHDS will grow 
<Mdily trm today's aifxroadaataly 10 paroant. 

It is sssiBcd thttt hoaidtal utilization by yaanguc patients will 
ocntinus to drop, but ipwR* ^assun ttm tha agingr population will 
cwarwhsla ttm doMnuaid trand - «U8ing CR.'VFall hoapxtal aAnissions to rise 
slowly. Ihtansity of cars will oontinaa to incxvaae, with greateo: 
sel«c±ivity in boapitalixing young people And incxeasing a±nissions of 
oldBr patients with ocsplaK problMas. Hoqpitals will oontiiua their 
vartioBl inbegr^jon as thiy seek to xvtain their ahare of the narloBt. 
Nan-iipatiant saxvioae incxease in fl s e sta nding omtsrs, the home, 
hoipioas, hoqpital oulyatiant dipartaMits, ate. Sena long^'tKn care will 
ta)Qa j^laoe ait hcB», but nadast aoqpansion in the simply of nursing heme 
beda will allow nursing hcaas '^o continue as tte chief long-tem care 
institutional sits. Houavar, affbrts will be wedt to moderate the growth 
of nursing hos* beds to contain costs. 

Vachnologi v that agppaar to be cost-effective will be adcptad and 
diffused into tha health care aystcai. "^tehnolcgies that pranise to 
ixprove outconas will also be souc^t, as will advancas that allow 
procedures to be done on an outpatient basis. 

Soanario PrnmartlVt PHYmmt; 

This soanario assiSNS that ptoepective payment becsonas the dominant 
paynent sechaniaa. Not only ilioq;>ital care, but acst other sorts of care 
win be paid on a proapectivr besis. Generally, payment will be at a 
preset, negotiated level, mde on a capitated or diagnosis basis. IK)6 
will gair a substantial ifhare of the market. Usuranoe ocnpanies will own 
and run »Ob and ROs. Xinslenni^ insuranoe wiU be eoqpensive anl 
infkequantly xised. large eaployer organizations beoona sofhisticated 
bargainers that s u ooe as fully oontxol health benefits' costs througfh 
negotiations witti intAxcanoa cce^aanias and ¥UDb, Those ozganizationB will 
bear risk and met eoearcise str ct utilization control, case Bmnagoient, 
and negotiate peymants to ensurw their profits. The nariaer of salaried 
physicians will incxease substantially. 

Hoapital utilization will be effected by the growth of Itcs and other 
managed care aystaas ttiat are suooselMl in controlling aAnissions. 
Although the upMurd y i i esm u e u of tl;a aging population is felt this will 
not Ijm sufficient to prevent a anall drop in av«»ll ho^ital. 
utilization. Hoapitalized patients %dll be mora serially ill so care is 
more oonplex. Within the hoapital there is a heavy enphasis on cnployee 
pcodiKtivity and ensuring that umeoessary or ineffective servioes are 

Outpatient, and other cost restraining delivery styls? will incxease 
rapidly in this scenario. Xhysicians not in managed care systene will 
broaden the scqpe of their practices, supplying an incxeasing range of 



MCvioM. All ttdsting outpatient mrvixxB buxgMn, and nm ones will be 
added as technology and entxepraneurlal pco^ddera take advantage of 

Technologiee seen to be ooet effective will be eagerly sougfht. Other 
technblogiee are v iewed wre ekeptioally. Ihsneaeed Mfahaeis on ensuring 
affective oera will enoourage incxteeaed tecijiology aseesnent. The 
nsults of each i is eaicli will be rapidly a^tad. 

fi^'^'^Y^p Ihpeag Aooeaa 

Ih this sonario pblicy decieions ere aede that attanpt to ensure 
aooesa to oere for all in need. Ihis oen be echievau by a lAfflbar of 
aachaniine uaed aingly or together. It oould be done by a achne of 
natioral health insunnoe which aiq^ i n oo c p a r a ta Bechmins of oost 
ocRtrol. It oould be done by eaqpanUng public pcogreBS, eoqpending 
aandatad insuranoe benefits, ensuring poynant to pre^ddare who care for 
urapcneored patients, xaqairing all en|>loyeni to preside adequate health 
insuranoe bmefits, and by oatastrqphic insuranoe fbr those with 

IncGBplata ocverage. Developing an adeguate "safety net" would halt the 
oost ehif^ to other peyere which is one way unxinwH i wit a rl care is 
sivportad today. This somrio is not an alterr ^ive to the first two 
scenarios, but oould occur in tanden with eittwr. 

It is esff^oad ^t whatever ftxnding axxangnents are nde, they will 
enooinrage individuals yJho would have tKJStjiu i a! "elective" procedures iji 
the a b senc e of ttdxA pai'ty paynent to seek care in a tijaely f addon iBther 
than deley seeidng cere .'sitil beocning eeriously ill. Ihus the intensity 
and ooeplexity of iifettient care will danreaee nrginally. It is also 
a«'^umed that funding will nade available for health prcmofticn and (Unmnft 
prevention eatvioes that are thoug|ht to decrease total health care costs. 

In Chapter 4 we ehow how the scenarios would affect dsnand for 
practitionere in each of ten allied health fields. 


Ihis chapter rtesn'lherl factors that drive danand in the health 
fields— including aqpects of population and enmnmir growth and change in 
financing and the structure of the health indbstxy. It also looked at 
foroes that say affect sivply of health oere wockecs-^^rowth of the U.S. 
labor fiocca and the college age population and trands in female artudents' 
Ghoioes of stud/ field, fbr eoosipla. Ihree health cere financing-driven 
scanarios lAiich decision sakani say find ueefUl tools in trying to 
evaluata the ftzture of epecific allied health professions were praeentad. 



Hdboaton, Mplcyws, ard othttB ara fboad vitfa difficult investment 
dacisicm in |>lanning fbr fUbm faunan iMumoa naada. Iha/ nist sate 
thair baat gnaaaaa about focoaa driving tha dnand anfl supply of 
i TOlcar a th air aa^iituda^ tha diracticna ttey My taka, and thalr 
intaractiona. Urn wmncm an not alwya cbvioua. Thara ia no oartainty 
aa to hw aaiiy AIDS patianta vlll laqiuira and xauaiva phyuica] tharapy 
aatvioaa, for aoonpla, or liiathar amutfiaaa «dll ba xoutinaly uaad to 
aczaan fbr oanoar. Diaplta tbm unoartainty, it ia poaaiUa to laam 
aoca about taov thaaa fteoaa influnoa alliad haalth anploynnt and thk. 
m^pply of wckaona. Ona, fbr asooi^la, aay track rtlaawaa and UaalimaiL 
pattama and hov alliad haaltii pcactitionara ara uaad, or nay identify nav 
tachnologiaa and datsBina ttiair liJoaly impact on alliad haalth aarvioes. 

Monitoring kay driving faroaa paraita uaafol insig^ into the future 
and allows one to battar datamina policy actiona. 



Jterioan Hoqpital AsBocdaticn* 1986* Racxaort en Uhion Accivity In the 

Hnlth Cum LAistxy. Ufxjbliflted paper* Septenter* Deper^oeit of Human 
RMCuroiS* Chioagp, Dl.i JkBarioan Hospital Association* 

taarloen Iio^pital Associatiai* 1985. Effscts of the Hadicare PKOspective 
Rrlcing ^ystfln on Hoqpilal Staffing Final Repott, Oun U act MkBiber HRSA 
84-386 (P)* Dmsbsr 31* Chiosgp, 111*: Jtesrioan Hospital Association* 

Anerican Riy*i08l Ihsnpy Association* 1987* MtapniBnt Ftactioe? 

OasHvits on draft backgrotf d pepsre pnparad for the Amerioan Society 
of Allied Health Pkofessiom' invitational OonfsrencsB, JUne 15-16, 
1987* My* 

Arg»lbm»r 8nd C* 6* Granrose* 1986* Hospital Btploynent Under Revised 
Hedioare X^tymint Schedules* Monthly labor Bm/im. August: 37-45* 

Banja, J* D* , and Wolf, S* L* 1987* Ifalpractioe litigation tar Uiinfomad 
Consent: Znplications for Rxysical lhenq)ists* Journal of ^ American 
Riyeical Ohsrapy Association* Vol* 67, No* 8 (August): 1226-1229* 

Bryer, C* N*, P. T* Swell, J* E* Finmey, and J* R* Kingle* 1987* 

Aeeesgmsnt and Outocoes Measuzvnent - A Vim firan the States: Hi^i^t 
of a Vm BCS Survey* MBOxh* BAication Oonsdssion of the States* Denver, 

Center for Bduoation Statistics* 1988* Perscnal ocniunication fton 
Dafara E« Gerald* Rn^isdnary projeccicns of education statistics to 
2000* U* S* Dqpartaent of Education* 

center for Bdtmtion Statistics* 1987* LaBs-lhan-4-Year Aiwards in 

institutions of Hi^^ Education: 1983-85* Dqpartsnent of Education* 
Itoflhington, D*C*: U*S, Ocvemnent Printing Office* 

Oviter for Education StatiirtioB* 1986* Hi^isr Education Finance Ttends, 
1970-71 to 19P3-84* D^r:art3£»^7nt of Education* Bulletin CBtl, OS 87-303B. 
Itatfdngton, D.C.. : U*&. c*?^>emiient Printing Office* 

enter for Eduoation SUtistlos* 1970-1987* Digest of Education 

Statistics* Amual REports* Department of Education* Nashington, D*C* : 
U*S* GoveniDBnt Minting Office* 

Ftillerton, H* N* , Jt* 1987* Rnojections 2000* lAbor fores prpjections: 
1986-2000* Monthly labor Rwiev. Vd. 110, No* 9 (Sept»ber): 19-29* 

Gilsartin, N* E*, and B* J* Mete* 1986* MKhanioal Ventilation in the 
HoBie: A Hmi Mandate* RMpixetory Qute, Vol. 31, No* Splay) :406-4U* 

Gore, N* T* 1987* The inpect of ERSs after year 4: A suing to better 
tises* Medical laboratory Gtaerver, Oeccnter:27-30 

. i 112 

(SHOnc. 1980. Saport of tte Graduata Medical Bdhicaticn National Mvisory 
OannittM to tte Sacxvtaxy, Vepao^sssA of Health and Honan Servicses. 
GMOnc Sonaiy Report, Vbl.l, Ho. 3. Itaahington, D.C.: U.S. Depaxtnent 
of Health and Hoaan Sarvioaa. 

Health CBia Flnancingr Mtainlstration. 1987. National health ai^endi- 

tuxaa, 1986-2000. n.S. OepartBent of Health and Hunan Services. Office 
of the Actuazy. Health Caza Financing Reviatf. Vol. 8, Mo. 4(Suainer) : 
1-36. ttaihington, D.C. : U.S. Govamnent Mnting Office. 

Health and Bann Sarvioaa. 1987. Mpoct of tha ladc Faroe 

on Medical Liability and nOpcactioe. U.S. Department of Health and 
Bnan Sarvioaa. Auguat. Itaahingtan, D.C. : Dqpartanent of Health and 
Hunaii Sazvioea. 

Health Cara Financing Adminiatration. 1988. Report to Congress. Study 
of Hone Rafipiratary ItMrapy. U.S. Depaitnent of Health and Human 
Services. Office of I^ibhohu.Ii and Deua- gti ations. 

hoalth na a ouica a and Services Adhniniatration. 1986. Report aC the Intxa- 
gcv^msital Task Faroe on AIDS Health Qu:e Delivery. RA)lic Health 
Servicea. U.S. Departaent of Health and Human Services. January. 

Jordan, G. L. , Jr. 1985. Rasidential Address: Ihe TBpwnt of Speciali- 
zation on Health Care. Annals of Surgery. Vol. 201, No. 5 
(Ma/): 537-544. 

MdKinney, H. T. 1986. State Oontrol of Hic^ Education in Michigan: 
A Nsv Scenario. Rdoliahed in Michigan Higher Education. Meeting the 
Challenges of tha Future. Report frun the Select OGnnittee on Higher 
Education. The Senate. lanaing Mich. 

Millner, R. , and S. Andea. 1985. Dif faranoes in Oonposition of Personnel 
Among Govamnent, V^untary, and IRvastorKXmed U.S. Otaaunity 
Hospitals. Exacutiva aoanary paper. Hospitals and Health Services 
Administration. January/February: 72-88 

National CHiber for Education Statistics. 1985. Rcojections of Education 
Statistics to 1992-93: Methodological Report with Detailed Projection 
OtdE^es. DBpartnent of Education. Nashington, D.C. : U.S. Govemnent 
Printing Office. 

National Cmtar for Health Statiatica. 1986. Health Uhitad States 
1986 and Ftavantiva Rnfila. Malic Health Service. Pub. No. (HS) 
87-1232. nenwifier 26. Department ol Health and Hunan Services, 
ffeflhington, D.C.: U.S. Govannent ftinting Office. 


National institut* on Aging. 1987. A draft pcgper cn "Peraomel for 

Health Naads of the Elderly lhxcug(h Year 2020." National iMtitutes of 
Health. DqpartBBit of Health and Haan Services. Riblic Health Sexvioe. 
Scptaber. UrgctliatmA, 

Offioa of nleenaa Rewntion and Health Itcnotion. 1987. Rnvantion 
Ftet Book. Malic Health Service. Dqpartsait at Health and Hunan 
Servicee. April. Naahington, D.C. ; U.S. OauianaaRt Mnting Office. 

Fereonik, V. A. 1987. ftojections 2000: mdustzy Output and Biploy^ 

nent ihraug^ Bvl of the Oentury. Ncnthly labor Rsviev. Vol. 110, Nb. 9 
(Saptanber) :45. 

Bnoqpec t tva Mynent nnnnriniiiiil Oomlssion. 1987. TKhnical Appendixes to 
the Report and Recaanendations to the Sacxetazy, U.S. Departnent of 
Health and Hunan Services. Rroepec t ive ItoyiMnt Assasanent Oonnission, 
April 1. 

Ridnan, S V., J. R. Snyder, and S. L. Wilscn. 1987. "Allied Health 
nofassionals and no's: A National Survey." Paper rnumMitiM.l at the 
Annual Haeting of the American Society of Allied Health Srofeesicn, las 

Saunders, N. C. 1987. ftojectionB 2000. Eoononic Rejections to the year 
2000. Monthly iJBbac Reviev. Vol. 110, No. 9 (Septeiter):U-18. 

Scandlen, G. 1987. Ihe CSianging Erprixamerit for Manadated Benefits. 

Uhpubliahed paper. April. Kashington, D.C. : Blue Cross and Blue Shield 

Scandlen, G. , and B. larson. 1987. Muiadated Ooverage Laws Biacted 

Ihrough nenfflrher 1986. Uhpubliahed tabulation. Office aC GovezTsasit 
Relations. Fafaruazy lo. Naahington, D.C.: Blue Ckoss and Blue Shield 

Suprege Oourt of CSalifomia. 1982. S^jzsij} v. Sortini at al . Oil., 
643 p., 2d 954. 

Ttafford, A. 1987. AIDS: The New Riase of Denial. Washington Post 
Health. JUly 28:8. 

U.S. Senate Special Ocnnittee on Aging. 1987. Aging America. Trend and 
Rpjecti' U.S. Department of Health and Hooan Services, Haahington, 

Natt, J. N. at al. 1986. Ihe Oonparative Wasrmic Parfan na noa of Investor- 
Owned Chain and Not-for-Rofit Hospitals. New Bigland Journal of 
Medicine. Vol. 314, No. 2 (January 9): 89-96. 




Major ecxxnnic danograqphic and social forces oust be taken into 
account in assessing the diractions and nagnitude of changes in the heedth 
care systen and their inplicationB for allied health enplcyioent. This 
chzqpter examines hM each of 10 allied health fields is affected by these 
fcroes and hov they will detemine the denand and siqpply for each field by 
the year 2000. 

Ihe diBCUSsicn deals with national trends, even though local 
decision naJoers concerned with allied health practitioners msy observe 
conditions that differ substantially trm the national esqperienoe. Ihe 
cooDdttee believes that its national analysis will be helpful to those who 
must draw conclusions about the future of allied health personnel in their 
own locality. 

The conmittee's assessment of the future is based on severed types 
of infonDation. BLS projections of demand are the source of quantified 
demand infoniation. To draw conclusions about demand, the connittee 
inoorpar a ted its own judgements about the iiopact of the maxiy fbroes that 
drive demand. Assessments of siqpply were made based on what would hz^^pen 
if the situation remedns unchanged with raepect to the rates with which 
individuals leave and enter the allied health wodcforoe. To that were 
added assesonents of the lilcelihood of the situation remaining unchanged. 
A final element in trying to foresee the future is {plication of the 
limited knowledge of current sifply and demand balances. Because decision 
makers aust even in the absence of oonplete data, the conndttee decided to 
make assessments of future labor markets for allied health practitioners. 
To do this BLS data was used. Chaqpter 2 described the BLS data collection 
and projection p roce ss . The conndttee advises readers to view the 
projections critically, in the light of their iiterent limitations. The 
projection should be intezperted not as a precise prediction of the 
future, but rather as indicating the magnitude of change. This can be 
used as a basis tram \itiidti local and federal decisions makers can develop 
their own best estimates of the labor market. The oonndtt^ emphasizes 
the ijqportanoe of data collection to eneble more precise {.^ec^ons to be 

The conndttee's assessment shows large discrepancies between supply 
and demand for allied hezdth practitioners in some fields. But, the 
conndttee is not suggesting that these gsps will necessarily occur. 



Rather, the aartet will eventually adjust eo that over time a reasonable 
balance is achieved. If enoployerB are sufficiently hard pressed they will 
raise salarieo, %AiLch will attract more peqple into the careers. 
Employers vhose ability to pass on costs is increasingly limited by 
proqpec t ive pennant, %dll aleo tzy to increase prodictivity and reduce the 
nonber of enployees as they beccDe more eoqpensive. 

The ccnnittee is ooncemed that the naxtat r cq po noo will not be 
gaidc or creative enough to avoid some negative consoqusnces such as 
erosion of quality of care, secvice disnptions and constraints on 
providers^ ability to aaka tixnely investaents in nev nodes of service. 
Because these are serious consequevxaes, the comnittee believes that it is 
ixoportant to try to antic^te veil enouglh in advance to forestall these 
disruptions if possible. Later chaqpters in this rqport are devoted to 
examining %wys in vftiich health care provider and educational institutions 
can act to protect thonselves, and ultimately patients, trm the costs 
associated with iiqperfectly vrrking maiicets. 

The ccranents \m nate about the way the year 2000 will look do not 
allcw for najor changes in the way health care is paid for. If a major 
financing change does occur, the ftiture of mmy allied health lields will 
be significantly altered. To shov the nature of the ijipact of financing 
changes ve apply the scenarios presented in Cheqpter 3 to each of the ten 
allied health fields dlflniwwd in this ciu^iter. 

In assessing the fixture denand for 'vxh of the ocopations, we have 
assumed that the current mix of fee-for-sarvice and prospective payment 
(mixed scmario) will prevail for the next 12 years. However, as health 
care policy decisions are taken both at the national and local levels, 
planners must adjust their views of fixture allied health enployment. To 
assist in this we have ixdicated how each profession mi^t be affected by 
ii»ntives characteristic of the ecenarios of ''access** (lAiich could 
ixiclude new state Medicaid entitlements or c nationally mardated benefits 
program) or the ••prospective payneit" scenario (lAiich could include a new 
state hospital rate ccmnission or the extension of FPS to settings other 
than acute care hoepitals) . 

We also alert readers to the significant trends in factors 
influencixig sqpply^-most often xvnter of graduates and educational 
programs. However, labor foroe behavior is equally ixiportant. 
Uhfortunately, sixioe only exude data exist on entranoe and ^t frcm the 
allied health labor force, we were able to make only very rough estimates 
of future sqply. ftiat we do Iokw is that even small dianges in tenure in 
the work foroe make large differences in the fixture supply. 



Clinical labontory Tachnologists and Technicians 

DBDBand for Nadical laboratory TBChnologists and Tedmicians 

Ihe EL5 pradicts that between 1986 and the year 2000 the nuxniber of 
clinical and laedical laboratory jobs for technologists and technicians 
will grew frcn 239,400 to 296,300, an imease of 24 percent. Although the 
grovth rate is below that forecast for many other allied health 
ooofMtions, it represents a substantial nmter (57,000) of nev jobs. By 
ccqpariscn, the expected dramatic 87 percent increase of {ixysical 
therapist jobs represents only 54,000 nev jcbs. It nust be remenbered 
that ttm BUS data are based cn enployere^ r e e p o nec i o to qLiesticns about the 
nuni3ers of people p er f omdng defined tasks. Raepcndents are not asJoBd to 
distinguidi licensed or certified p ers o nnel frcm those without such 
ctedsttt i hi H m 

Clinical labaratories are in a period of rapid change. Techno- 
logical changes are enabling tests to be conducted in nev settings, and 
are generating nei^ tests. WS has caused hoqpital managers to rethiidc the 
relative roles of in-house and reference laboratories. Changes in 
reiiAureanent have caused i^iysiclans to seek the benefits of providing 
office labQcatory services. Nev settings for health care, such as 
aiEbulatary centers, are establishing laboratories in nan-traditianal 

ttien analyzing these changes in terns of their iiqpact on demand for 
technologists and tedmicians, it is iooportant to distinguish betuem 
changes reducing demand, changes increasing deund, and changes that make 
no differenoe to manpower but cnl/ represent a changre in location, 
techniques, or practice style. 

Sinoe appraximately 63 percent of clinical laboratory technicians 
and technologists are enployed fay hoepitals (see Teible 4.1) , changes in 
that setting will have great influenoe on the demand for those personnel 
and on inhere they watk. A njabeac of factors thar sre affecting tte 
hoepital laboQcatory %orkload may, in turn, affect panscnnel needs. 

The introduction of the resultant reduction in oocupanr^ rates, 
the incentives to prcvide less costly care, all affect hc^it^ 
laboratories in several ways. Many hospitals have increased their use of 
reference laboratories for epecialized tests, concen tr ating in-teuse 
laboratory nock on %ddely used tests with %Aiich econamies of scale can be 
achieved. Sinultaneously much preadmission testing is done on an 
outpatient basis, and inpatient test mix has changed as more oonplex cases 
are adtadtted. Aooording to the American Hoepital Association, foll-'time- 
equivalent (FIE) employment in U S. registered hoepitals fell between 1983 
and 1986, ulth medical technologist enployment falling by 2.4 percent. 
FTE enployment of other laboratory perecmel fell by 5.3 percent between 
1983 and 1985, and rose by 2.1 percent in 1987 (American Hoepital 
Association, 1985 and 1987) . A surv^ of the early inpact of Diagnosis 
Related Groqps (ORGs) on 122 hoepital laboratories noted that 63 percent 
of hoepitals eoqperienoed increased test volimie in 1983. This had fallen 
to 32 peromt of hospitals in 1984. 


- 4 • 

The nuBter of hospitals «)qperi«ncing dBcraaaerl voIvbdb aLnoet doubled frcn 
24 peromt in 1983 to 44 peraent in 1984. Tha iiqpacb on staffing was 
otea^vahls. Fifty seven pettaent of laboratories reduced eofdoyQent after 
FBS—- only fbur p ercen t incxaased enoployDent (Hadical laboratory Gbserver, 
1984) • Ihase early changfes ledbcing denand did not continue. Utilization 
and budgets azB grtwing bigger and staff reductions have abated (Gore, 
1987) • Sixxae hoq>ital oinsus is thouc^ to be a less reliable laboratory 
%»rkload pcedictor than the eeverity of patient illness (Harper, 1984) one 
aust look to the patient mix for explanation. With an aging populaticjn 
severity of illnass is rising. Althoug|h the nanber of lab itens per 
discharge had fallen substantially during the early years of FPS, it rose 
19.8 percent in 1985. Possible reasons fbr the upturn include increased 
case ccnplexity, less opportunity to diift to outpatient settings and less 
opportuni^ fdr eliminating umeoessary services (Rcoepective PayaBsnt 
Anannnrnnnt Oomnission, 1987) . 

Madicare is not the only payer trying to reduce laboratory vork. 
Other payers are beconing increasingly conscious of laboratory costs. For 
exanple in 1987 BLue Ckois and Blue Shield issued Diagnostic Testing 
Guidelines for appropriate use of 13 laboratory tests. Some of these 
tests are routine hoqpital admission or pre-tsperative tests. While these 
guidelines were not associated with coverage rules, the reconiQendations 
are mpecteA to be adopted by most of the plans, and possibly by other 
insurers (Afaramo&dtz, 1987) . Efforts lite that of the Blues may herald a 
mve frcn exhaustive testing more targeted use of laboratory work. 

Technological diange affects clinical laboratories in all settings. 
Mhile there is discussion of autcmation in the laboratory-^even robotics — 
reducing personnel needs or lowering the needed skill level, there is 
potentially offsetting concomitant developraent of new and oonplex, 
labor-intensive, non-automated tests. 

Technological changes together with financial incentives and 
patients' desires hav^^ stimulated physicians to mate laboratory services 
available in their offices. Several surveys have been conducted of the 
extent of this practice. Estimates of the nuni3er of physician office 
laboratories range fron ai:p(roocimately 80,000 to over 250,000 (American 
Society for Medical Technology, 1986) . BL5 estimates that 30,100 
technologist and technician jobs exist in physiciam' offices. Ihis is 
expected to rise to over 46,200 in 2000. Observers close to the scene 
pttceive diminidiing enthusiasn for small {iiysician office laboratories, 
possibly because they are not proving to be cost effective, and possibly 
because of e}qpectations of increased regulation to control quality. 

Tk9o iaportant questions for laboratory warpcMesr denand anerge from 
the physician office laboratory Fhencmenon. One is i^hether physician 
office tests are additional tests or substitutes for testing at other 
sites. Another is %tett)er physicians enploy clinical laboratory 
technologists or technicians. No evidence exists to armer the first of 
these questions. On the question of staffii^, a literature rwima 
concduded that personnel other than technicians and technologists ar*-^ more 


TMLE 4.1 1 Mlctl and Cllnieal Laboratory TodmolofUtt' «id Ttdinlclm' Major 
Placat of Ui9a ind Salary bployMnt, 1966 and 2000 ^rojaotad 

•fcatotr of Jofaa mab%r of 

1966 Stream' 2000 Ptrcant^ 

Total Cii|>loywt^ 239,400 296,300 

Total Wiot A Salary 

"^l^^y^nt 230,400 lOO.O 295,200 100.0 

Noapftala, public 149,800 62.6 160,000 54.2 

and prfwata 

Officaa of phytfcfana 30,100 12.6 46,200 15.7 

Off fcaa of dtntfata 
and othar hoalth 

practUfontra 890 0.4 1,800 0.6 

Nfdlcal and dcnt^. 

taboratorlaa 26,100 11.6 43,200 14.7 

Outpatfant cara 

facflUfaa 5,300 2.2 13,000 4.4 

SOURCE: U.S. DapartMnt of L«bor, Buraau of Labor Statiatics. 1967. "fiiploywnt by 
ocojisatlon and Industry, 1966 and pf sjactad 2000 altamatfvts." Noderata 
altamatfva. (Unpubllahad.) 

^ ftrcantagtt Mara ealculatad ualng vnro^Mrdtd figurat and ulll tharafora not ba 
Idantlcal to parcantagaa that aay ba ealculatad uafng tha roundtd ffguraa provfdtd 

^ Total EiployMtit « waga and aalary a^ployiwit ♦ aalf anploywent. Includes 1,000 
aalf-a^ployad Norfcars In 1996 and 1,027 In 2000 Mho ara not allocatad by Industry. 


- 6 - 

litely to do Uboratory work in GBonall or solo proctloes. Often nmses are 
used. Ttm larger the practioe the mora likely that trained laboratory 
perMnml are cnployed. One study found cmr 50 p e rcen t of qccap 
practicee eaplcywl nedloal tachnologiBts (ftoet and Sullivan, 1985) . 
However, ciiangee in the staffing of T^t^micim of f ioe laboratories nay be 
en the %iey. Oongress has enacted provisiGns that will reqioire office 
laboratories that perfom nore than 5,000 tests on their own patients to 
OGnf om to tbB Madioare conditions of participaticn set for ind^sendent 
laboratories. Ihis is scheduled to beocme effective in 1990 (ASMT TcxSay, 
1988) . Technologists in i n d epend ent practioe are f i^viing incanaasing 
opport^lties as consultants to physicians iho need help with calibration, 
qoality cxxitxol, test interpretation, nore soiiiisticated procedures, and 
nanagenent of their office laboratorler. 

Other nsv sites for laboratory %iQrk include HOs and anbulatory care 
centers. Although 5,500 such centers are projected to exist by 1990, not 
all will employ hi^y trained lab perscnnel. At email centers, nurses 
and x-ray technicians oftm perfom routine tests, with cross training 
condboted by the facility owner (Baranowski, 1985) . 

Ohe developnent of IK) laboratories is providing enployment 
opportunities in a new setting, but this enplcyment site should not be 
thcuglht of as increasing denand for personnel. Indeed, in the long run, 
as IMDs in ocnpetitive emiroments start to seek new ways to control 
costs, it is reasonable to speculate that a reduction in demand for 
laboratory wrk nay be brought about fay curtailing siperflunus testing. 

Future demand for clinical laboratory perscnnel has thus far been 
rtlfinififlflrf as if changes will affect technologists and technicians 
equally. Miether this will be the case is unclear. Althougjh inoentives 
to reduce cents night lead cne to eoqpect enployers to seek to use the less 
eoqpensive personnel, at tines nore hic^y trained staff can be nore cost 
effective. Similarly, acme technological changes, such as increased 
autcnaticn, nay allow enployers to eaqpand their use of technicians or 
on-the-job trained personnel, others will require nore highly trained 
staff. Ihe trend appears to be toward increased use of hi^er level 
personnel with denand for lower levels strengthened by difficulties in 
hiring hi^jher levels. A 1987 survey of the American Society for Medical 
Technology nonhers reports this nessage. •*ftere hiring has occ u rreJ in 
the par*: two years . . . nore technologists with the bachelor degree were 
hired than were clinical laboratory technicians (GUDs) . Ihouc^ seme 
facilities reported substituting specialists and nore sdvanoed perscnnel 
for entry-level practitioners, other reported hiring more OSHs and 
on-the-job trainees (QJTb)— to some extent as a result of a shortage of 
clinical laboratoocy scientists (OS) professionals** (Rrice, 1988) . 

In sum, mrv of the changes occurring in clinical laboratories 
involve alternatives in the places in %hich testing ocours. Some of these 
are q;urred by financial consideraticns, seme by changes in the stricture 
of the health care delivery system. Generally these changes do not affect 


ttm dflnand for txainad personnel in a aajor voy heoiuse they do not have 
signifioant lipacts on thB ruAxxm or typeB of tests ocdered. Although 
scne extra testing is stimulated ky the new settings, not all the voric is 
being done by clinioal labaratary technologists or technicians. A 
vlth laboratocy %iOQck that has surftaoed in the popular press, and has been 
voiced by the professional associations, relates to giutLity. Reports of 
inaccurate tKP anear readings and false positive AIDS tests have focused 
often on the laboratory personnel— -vhich could result in increased donand 
for licaneed peraomel, or in the hiring o^ sore personnel of all kinds to 
relieve pressures on staff. 

For ttm future, dcwnuozd pressures on test volune caused by payers' 
attenpts to reduce costs will be of foet by qpmrd pressures as new tests 
are developed and the aging population denands nore service. Similarly, 
technological change will cause as mLich expansion as reduction in demand 
for trained personnel of all levels. 

Grow^ in demand for medical and clinical lab technologists and 
technicians %dll derive frcm general esqpansion of the health care 
industry, the aging of the population, and an increase in some specific 
trends such as increased therapeutic dnig monitoring, testing fbr 
substanoe «dbuse and AIDS screening. Together, these qpward pressures 
ehould lead to cnployment growth at a rate that could even exceed the 24 
p ercent groiirth to the year 2000 predicted by the HLS. If either AIDS or 
drug testing b e ocin B S widespread, demand for clinical laboratocy 
technicians and technologists will flnrther increase. Ihis rate of 
increase could be reduced if , as is li)cely, tests eventually beccme more 

Fectors that would cause denaand to change significantly and should 
therefore be monitored by those atbeupting to track en|)loyment of di'tical 
laboratory perBonnel include: 

o policies concerning AIDS screening 

o policies concerning substance abuse testing 

o technological change 

o payers' BtXmpts to ccntrol test vdune 

o quality concerns. 

o trends in state anchor federal regulation of laboratory 

Ihe three scenarios described in Chapter 3— mixad financing, 
prospective payment, and aocees— have seme straic^htforward ijiplicaticns 
for demand for clinical laboratory technologists and technicians. Under 
the mixed model, growth in jobs is expected as described earlier^-pocobably 
in eoeoess of 24 percent to 2000. If proqpective payment beccnes dominant, 
laboratory testing will come under scrutiny and incentives will ensure 
that all testing contributes to clinical management of patients. 
Technological changes to inprove cost-effectiveness and decrease 


- 8 - 

pttBomal, both in encutit and level, will be adopted. But demographic 
pcessures will still exert i^Maxd pressures, m sidb, danand will grow 
at a slcMer pace laxler the prtsepective payment nodal than under the 
nixad financing aoenario. If a policy to e)q>and aooees to health care 
oooirs, additional individuals receiving care will increase daoand in 
all settings. 

Sifply of Medical Technologists t Medical Zaborataty l^echnlcians 

Ohe ruabeac of baccalaureate graduates in the field of medical 
technology has Oxjun a dcwnuard trend since the end of the 1970s. In 
1986 there %«re 4,477 medical technologists graduated, dcMn 28 percent 
fton 198G. The rater of accredited p ro giai B B for medical technologists 
also deoraased, 26 peroent over the ten-year period ending in 1986. 
Hoepital-faased proyiama dosed most frequently, but closures in general 
ooaorad because of budget restrictiocB, the iii()9ct of WS, a lack of 
9ialified applicants, and a dec r eased need for laboratory personnel in 
the ianediate geographic area (Otmnittee on Allied Health Education and 
Aocreditation, 1985). 

IXjring the past ten years, total certificate medical lab 
technician piujiams denrBaeed 69 percent. But the associate degree 
i PBdi c al lab technician progr aH i s increased over the ten-year period, and 
they i n c r eased over four-fold, tran 38 pr ogr a n s to 214 progr a ns. 
HcMever, between 1985 and 1986 there was a 5 percent drop (Ocnoiittee on 
Allied Health Education and Accreditation, 1987a) . 

Ihe trend in the certificate and associate degree trained 
personnel (technicians) is less clear than for technologists. Although 
the 2,747 graduates in 1986 represent a 9 percen t increase avw 1980, 
graduations peatod at nearly 4,000 in 1984 and have trended dchmiard 
since then. There are two routes to becoming a technician. One is 
gnduation trm a certificate progrrim. cnly 817 medical laboratory 
tedmicians graduated ttm the certificate prograns in 1986, down 24 
TpexoBxA trm 1981. The other route is via associate degree prograns, 
from vAiich the ninber of graduates increased 11 percent over the 1981 
nmfaer, with 1,930 graduating in 1980 (Oomnittee on Allied Health 
Education and Aocreditation, 1987a) . 

At the start of this study anecdotal evidence frcn educators and 
others pointed to a surplus of clinical laboratory technicians and 
technologists. But during site vi sits anS discussiors with 
kncwledgeable ofaserMtrs towards t; ^ middle of 1987, the conmittee began 
to hear of managers having trouble hiring staff for clinical 
laboratories, other reports confirm this change (Meyer, 1988) . Other 
evidence K^ports the suggestion that the Irbor maricet is getting 
ti^fhter. A survey of directors of accredited education piuyiai i s shows 



that bctwMn 1981 and 1986 the percentage of directors \Aio considered 
the job ZMZkst for laborutoty tedmicians and technologists to be 
attractive increased eukstantially (Iteks and Hendrik, 1988) . An 
Jnfocmi surviy by the Anurican Society for Medical Technology foum. 54 
petcnt of onmtituant societies reporting an underBupply of clinical 
laboraocy technologists, lhat tigiae ues 38 percen t for technicians 
(Heyer, 1988) . A study ccaniesicnBd by ttiB Health n Bsc iurooo and 
Services Jkkiinistration notes that ahoctages of nedical technologists 
are ooourrlncr in some locales (Hrthenatioa, 1987) . Stataidxle surveys 
in North Oarolina ttxM the vacancy rates for clinical laboratory staff 
increasing from 4.6 percent in 1981 to 16.5 percent in 1986 (North 
Carolina Area Health Bkioation OBnters Kogram, 1987b) . HcMsver, the 
ip.i1yr1a« of technologists and technicians onployed in hoepitals betMsen 
1981 and 1986 increased 24 and 21 pr:x3eg±, respectively. Ihis increase 
is low ccBi)i>*w1 %dth 18 otter ^pes of hoepital «q;>loyees— of these 
aqployees a y ;;.igineering technicians had an increase lower than 21 
percent (University of Texas, Medical Branch, 1985 and 198") . Ihis 
suggests that the difficulties in hiring nay not hove surfaced in 1986. 


MBddng statements about tte liJoslihocd of future balances or 
intalances between stfply and denand for clinical laboratory personnel 
is ccB{)licBtad by the Bultiple routes of entry into laboratory irork. 
Laboratory vorkets nay have four or more years of postseoondaxy 
edbcatiai or nay qualify through a conbination of diorter educational 
ptugiame plus eaqperience. Baccalaureate prepared technologists need 
less supervision than other personnel, and hold a variety of 
hi^wr^level jobs such as laboratory director, aanager, consultant, and 
education ooordinBtar for hoepital schools. Technicians aay have 
twD-^ear associate degrees or oonbine edur::.«uon and eoqperienoe t: 
becQDB certified throuc^h a professional organization. Other laborattsry 
wDrioBTs are certified in tpecial areas, such as cytotechnology or 
heniat6].ogy, and otters i^vf hav« qpecialist certification in dieciplin^ 
such as blood banking or microbiology. Finally, there are large 
nnbers of uncertified woricers as indicated by tte discrepancy between 
tte BUS job count and tte nnber of certified persomel. These 
Bultiple routes of entry into a career in clinical laboratories make it 
difficult to assess tte suqpply of labcratory vorioers of tte future. 
Thking into account tte ccntpaxatively acdest expe c ted growth in new 
jota, anl assuming ttet workforce behavior and staffing patterns do not 
change radically, graduations frcn clinical laboratory piuyia n s should 
te sufficient to ketp denand and supply in reasonable balance to tte 
year 20C;' if tte rate of graduation is stwtainnrt at its current ICMel, 
at a mininun. Ote recent decline in tte nnber of graduates Bust te 
halted. If this decline dxjuld continue, some isprovenents in salary 
and working conditions should te expected to bring sufply and denand 
into balance. A mnber of farmers make prognostications In this area 
tentative. If tte growing nunber of bicosadical technology firms becone 

■ajor UMTB of labaratoxy pencnnel, diverting trained personnBl fnxn 
Glinicaed lAboratorlM, galarics and benefits %iould isiatov^ as anployers 
oexpete for trained parmnel. If the parBCxml trained in disciplines 
such as ciMBdstry and aiGzti>iology an no longer available to Mdioal 
laboratories there be pnblenB Imrmieii these persomel are used 
to fill jobs iten tte labor sarkat is ti^. A significant change 
could ooBtt about as a result of nplciyers using perscmel differently. 
For instance laboratocy sanagers nay choose to substitute one level of 
perBomel for another* 

VLdti fle)cibility is possible. Today ther^ is scbwHibrs litUe or 
nc differentiation in tim wy technologists and technicians are used. 
This could change. Finally, if a four-year degree beormB mandatory 
for licensure, and licensure beocmes a more widespread requirsnnit, the 
balance of sqpply and dnand oould be severely diisr\t*ed. There is 
increasing debate conoeming the ; cos and cons of licensure whose 
pucpose is to differentiate jobs accordiiig to aoadenic qualifications. 
Ihe scope of this study did not a>^t of a ccnclusion on this natter. 

As a final note, ttm clinical laboratory labor sarket seesB to 
adapt rapidly to changes, such as changes in health care financing 
incentives. In tiie course of this stidy the reports of graduates 
having a hard tine flndUng jobs vere su oo eeded by reports of shortage. 
nwiOTTw given for this turnaround are varied. laboratories nay have 
allowed staffing levels to sl^ too far in an c^erresponse to 
p iuspec t ive payment. laboratory vdune nay have risen faster than the 
sifply. Others nay that the level of stress at the worksite has 
increased because of productivity pressures and increased conplexity of 
care. Fear of AIDS adds to the stress, and salaries are not high 
enough to oonpensate, so people are leaving the field (Mayer, 1987) . 
If these factors do generate nn increase in the separation rate fkon 
the labor force it yaoLd have a significant negative isnpact on the 
simply of \9orkers and necoessitate greater narket adjustnents. 

Dental HygienLsts 

Demand for Dental Hygienists 

Ohe BUS estinates that in 1986, 86,700 jobs for dental hygienists 
existed. By 2000 this nunber is expected to have increased by 63 
percent to 141,000. Ihis rapid growth is based on several 
oonsiderationB: First, BLB analysts consider enploynent growth in 
dental offices to be the most iisportant element in generating jobs for 
dental hygienists because the vast majority (97 percent in 1986) are 
enployed in that industry sector (see Table 4.2) . The BL5 projection 

TAILE 4.2: OtnttI Nygiinltta' Mtjor ^ItcM of Itogt and Uimy Biploywnt, 
19B6 and 2000 ^rojocttd 

IMrfw of iote 



mmUr of iote 


Par cant ^ 

Total imployMnt^ 



Total Uaoa i Salary 






Offfcaa of Darvtiata 





Mmctt U.S. DapartMHt of Labor, iuraau of Labor Stattatlca. 1987. "EaployMant by 
oco^tten and Industry, 1966 and projactad 2000 altamatlvta." Nodarata 
attamattvo. (Unpiftltabad.) 

Nrcantagaa Mar« calculatad uatng tirowda d figuraa and nil I thorafora not ba 
Idantfcal to i^cantagaa tnat ny ba calculatad wlno tht roindad f fguraa provfdad 

^ Total Byloyint ■ uaga and aalary aaployiaant ♦ aalf a^ployiaant. Salf-anployad 
paraona ara not allocatad by Induatry. 

12 - 

fdr dental Ixygianist cnplqyDfiiTt is ha&perBd by data oollecti^ problesns 
that applies only to this sector. The survey cn vhich the BUS data are 
based wes mmA to incxirporated businesses oily. A hi^ piroportiGn of 
dentists are not incxsporated and therefore not inclixlad in the survey. 
Dantists offioes prrvidad nearly 460,000 jobs in 1986; this nunber is 
projected to reach 706,000 by 2000, a 53 percent increase. Contributing 
to this eoqpensicn is the H[S eo9)ectatiQn that the nater of voridng 
dentists will substantially increase by the year 2000 (fkta 151,000 to 
196,000, alaost 30 percent o je tm e J with 19.2 percent for all 
occupations) . Noireover, ttieee dentists are eoqpected sustain their 
utilization of dental hygienists. BIS analysts believe that the entrance 
into tbB dental profession ot younger dentists, i4io are tanuigiht hw to make 
effective uee of hy^i^nists will cause the ratio of bygienists to total 
dentistal office staff to inczease sllg^itly. 

Other assuqptions on vhich BIS has tesed its hi^ growth prediction 
include continued qpread of dantal insurance that will generate farther 
demand for dental eervioes, and the aging population's need for dental 
services, pertioularly people retaining their teeth for longer, and the 
**baby boon** generation's entry into middle age \t)a\ periodontal disease 
ix'uxiiiKs more prevalent. 

Ihe BUS notes that dental hygienists are often hired on a part-'time 
basis. To be fUlly eeployed a hygienist will often take two or more 
part-^time jrte. Ihe projection of 141,000 hygienists' jobs by the year 
2000 met therefore be substantially decreased to be translated into the 
nater ot hygienists enployed. BL5 analysts suggest that the reduction 
could be as high as 30 - 40 percent, which wuld result in an estimated 
84,600 to 98,700 enployed hygienists in 2000. This estimate is supported 
by deta trm a 1982 survey of 1,503 dental hygienists. Ihe survey found 
that 29 percent of leepondents worioed in more than one location, 
indicating wltiple jobs for most of this group. Six percent worioed at 
three or more locations. (Dental Hygiene, 1982) . 

Ihe demand for hygienists depends on the number of working dentists 
and the level of activity in their offioes. The level of activity in turn 
depends on the prevalence of dental disease, the extent of dental 
insurance and the willingness and ability of uninsured people to pay for 
dental treatment. 

Ihe QES assuxc'tion ttuxc the rate of growth of hygienist jobs will be 
double that of dentists depends on dentists being bi»y eraug^h to want to 
cnploy hygienists. Dental insurance has exhibited rapid growth (fkan 12 
million to 81 million people between 1970 and 1980) , and there is still 
untapped potential for further growth. But eome analysts suggest that the 
rate of tte epread of dental i*-*«urBnce has past its i»ak. **lhe easy 
pickings have been gathered" ost large multi-state enplcvers new offer 
dental benefits (Bishop 1983) • ihe question renains vhether'the 


- 13 - 

stiaulaticn trm incxBased dental insurance will be sufficient to offset 
the mtt&dt of dental ^^nnnnn p re v en t ion such as fluoridation and regular 
nalnbenanoe csare« A najor factor vill be the extent to which dentist:^ can 
expand the RShsr of restorative treatments thsy perform. 

Over 70 peroen c of dental costs are paid out-^f-poctet and price is 
the most often cited barrier to dental care, as a result only 
approDfiTOitely half of the pqpulatlon visit the dentist each year 
(GrenirsMBki et al. , 1984) . Ihe Bureau of Healtt Rroftesicns (EHE^*) in a 
recent report notes the relationehip betMen dooand for dental care and 
national eooncnic growth. WPr used two diffeirent data series for dental 
expenditures to develqp f^recMte to 2015 using two scenarios of eoGnGnic 
growth. For neither data set and scenario does fixture growth in dental 
eoqpenditures reach the rate of growth observed fkcn 1965 to 1985 (Bureau 
of Healtti nnofessicns, 1987) • Althouglh the nnter of enplqyed hygenists 
per dentist has increased substantially (fkom 4.0 per lOO in 1950 to 33.3 
per 100 in 1986) , the rate of increase sinoe 1981 has been very slow. 
(Bureau of Health Rrofessions, 1987) . cnly in thB unliJoely event that 
dentists become very busy will the nonentun of the 1950s to early 1970s be 

There is also reason to question whether the BUS estimate of 196, 000 
dentists in 2000 is not too hi^. The nnber of graduates from dental 
schools peeked in 1982-83 and is expected to continue to decline reaching 
the level of the 1950s by the year 2000 (Solonon, 1988). Since dental 
schools have closed as the perception of an oversupply of dentists affects 
career decisions, tHPr eoqpects dentists to nunter 156,000 by 200O— seme 
40,000 below the ELS estimate of dentists jobs. 

Ihere is clearly great potential for increased use of dentistry. 
Scne of the potential will be realized by expemian of insurance and 
grovth of real inocne. Scne esqpansion ^dll stem fkan increased 
periodontal disease and other cpportoiities for intervention with new 
^pes of proosdures needed in an aging population, fie question whether 
these increases will be sufficient to allow dentists to enploy hygimists 
at the rate predicted by BIS. 

Ihe opportunities for enploynent of hygienists outside dental 
offices are limited today by regulations rsguiring then to work %dth 
dentists on site. Ihus, populations such as the elderly in long-term care 
facilities, and physically and mentally retarded peqple in institutions, 
whose access to dental care is limited by their lade of mobility, cannot 
be served by hygienists alone. Althcug|h many in the dental hygiene 
profession are flg|hting the regulations that restrict their independence, 
if in dgperate nt practice is achieved it should not be viewed as cmting 
demand unless the regulations are changed. 


m mm, altiioug^ the luiber of jdas for dental hygienists will 
oontiniB to grov, it nnnm unlUoely that jcte will coqpand by over 60 
p eroen t by 2000--twioe the hig^ rate of ejqpansion pcedlcted for dentists. 

The major factors that those oonoemed with future daggand for dental 
hygienists ihculd txadc indude: 

o the iu±er and age cf working dent 'sts 
o the coetent of dental insuranoe 
o growth of zeal perecnal inaone 
o dental diweMc patterns 

o changes in the practice of dentistzy that influence 

oonsuL-m' attitudes towazd dental use, i.e. . technological 
develcpnents that nay reduce the pain of dental treatment 

o changes in staffing patterns in sole and group dental ctf f ioes 

o p i o gie ss touard independent practice. 

The three scenarios dnsrrihed in Chapter 3 are driven by changes in 
the financing of health care. Financing of dental care is often 
independent of the financing arrangements for other types of health care, 
tterefote thit differences in daoand for dental hygienists caused by the 
financingr-driven scenarios are email. Uhless dental care beocmes a usual 
ccnixxMnt of the benefits package in prepaid health plans, the toqpstsian 
of such plans envisioned in the managed caze scenario have little ixpact 
on demand for hygienists' services. Similarly, unless access to dental 
care is included in policies that increase access to health care 
generally, demand for hygieiists will be remain unchancied. 

SucDlv of Dental Hvaienlgta 

The Council on Dental Education reported that 198 accredited dental 
hygienists pLujians graduated 4,037 hygienists in 1986. Ohe nunber of 
graduates declined gradually between 1980 and 1985, with 22.4 peroent 
fewer people graduating in 1985 than in 1980, but showed a slight tptum 
in 1986 (kmtijom Dental Association, 1987) . 

Although most accredited dental hygienist p rogramB regoire tuo years 
of study, or its equivalent, the nunber of p L xjgiaas talcing three or more 
years to oon|)late has been incTBasing. in 1985, 33 peroent of all 
programs had this longer reguirement. Ohus the time taken to produoe a 
dental hygienist is inczeasing. Bfitzy requizanents are also inczeasing. 
In 1970, 80 peroent of the piuytaiati required only a high school diplcna. 
Ey 1985, 64 peroent of the piugianis still used the hig^ school diplcna as 
the minliwim qualification for acceptance, but 23 peroent of the prograns 
reqoized some college courses. 

Representatives of the American Dental Hygietie Association and 
anecdotes suggest that ir> acne JocaticnB there are acute shortages of 
hygienists. m one such ^ '<^i1^, after a surv^ confimed ethortages, the 

- 15 - 

denta:. association %ibs willing to financially help the ccnnunity oollege 
cxnate a new liygienist program. This is an exaqple of the sort of 
aujustnents that are made to rectify labor market islaalanoes (McNahcn 


Ntether the luriber of dental hygienists available over the next 12 
yeus will be enough to maintain a good balanoa between supply and donand 
depends in part on whether the decline in the nuniser of dental hygiene 
graduates can be halted. If ttere is no Airther decline in graduations 
there efaould be no need tac major labor market adjuecmBnts. But, in order 
to halt the decline SGue changes must take place; dental hygiene must 
beocne more attractive to proqpective students. Ihis will happen if pay 
is increased and working conditions are iaproved. Resolution of some of 
the tensions between dentists and hygienists (which are disaiiBserl in 
Chapter 7) may prove to be a key to inproving wcwridng conditions. These 
changes would also decarease the nmiser of workers leaving dental hygiene, 
and bring brick into the wockforoe scne who had left. Relatively nail 
adjiistnents now would avoid future dislocations and major adjustments 


Demand for Dietitians 

The Bureau of labor Statistics predicts that b^' the year 2000, 
53,800 dietician jobe will exist— an increase of 13,600 jobs, or 34 
percent over 1986. Ohis growth rate is the same as the BL5 expects for 
respiratory there^ ancl apeech pathology, but substantially below that 
mpxted for some other allied health ocopations such as physical 
therapy, dental hygienists, and radiologic technicians. 

Ihe BIS data show that nursing hemes and ho^itals are the major 
sources of wage and salary jobs (rouc|hly 14 percent and 39 percent 
respectively, see Table 4.3) . School systesB, public health departinents, 
IfDs, and anbulatory fiacilitiee each eaplaf snail nunters. Biployers such 
as retail eating and dining places, publi^iers of nutrition and other 
magazines, diet counseling services, child care centers, and food 
manufacturers also enploy anall numbers of dietitians. BIS data indicate 
2,000 self-«i{>loyed dietitians in 1986; this figure is projected to rise 
to 2,700 in 2000 (five percent of jobs in both years) . A 1986 sun^ of 
meniDerB of the Anerican Dietetic Association confirms that ho^ital and 
extencM care facilities are the primary aqployers, enploying 54 percent 
and 10 percent of foll-'timr nenters, respectively. Ihe survey also notes 


16 - 

that althcuglh only 3.7 percent of full^-tiiDe workars vera self aqplGyed, 
over 33 peroent of dietitiane «te %K3rk part tiaa vera aelf-enplGyed (Bryk, 
1987) • BLS estinatae that cdMit 5t of jobs vara flUad by aelf-coployed 
pecple. Dietitians thus differ trm nmy other allied health oocqpations 
in their variety of asploynent settings and sonsuhat lesser dependencx'^ ori 

Analyzing enploynent in tezsB of factors that will either stimdate 
or deprass demand indicates ^t overall sscd^ growth can be eoqpected, 
probably lower than BIS projections. Ftetars tending to restrain growth 
include slow growth of the hospital industry. Bidead, it is notaible that 
FTE fln|>loyBent in hoqpitals daczeaaed even before the introduction of FPS 
and the decxease aooalerated thereafter (Jlnerican Hospital Association^ 
1985 and 1987) • However, all of this raducUon in hospital enployment is 
not necessarily a reflection of reduced use of dietitian services by 
hoqpitals. Hoqpitnls can co ntra ct for services rather than dizBctly 
osploy dietitians. Sij&ilar changes nay be taking place in nursing hemes. 

lha wwe to out-of-hOGpital services is liJcely to produoe a modest 
fihift of aoDployxnent to anbulatory clinics but no significant change in the 
nunter of dietitians anployed. Althougjh proepective payment for hospital 
care is causing ixKzeased need for hone care, the growth of dietitian 
CB|)loymBnt in hone care is iiiiibited by Medicare rainisurBenient regulations 
that prohibit dietitiam billing for home visits. Rather they are 
included in adninistrative eoqpenses of home health agencies. A study 
charged with making raii±urBenent recoBnendations to Congress noted that 
although dietary therapy is iflfnrtant, and necessary for a wide range of 
diseases, the pi ' cgmiL reinbursement a p p co g ^ is adequate (Health care 
Financing Administration, 1986a) . Another factor that can constrain the 
grcwtn in demeuxl for dietitians is the extent to which other professionals 
such as nurses or health educators are thouc(ht to provide substitutable 
services. In the current environaoent of price ccmetition, except for 
some qpecific tasks, dietitian duties could conceivably be eliminated or 
perf o rme d by other personnel. No data cn this pheronenon exist, however. 

On the other hand there are factors increasing demand. One such 
factor is increased use of hig|h technology nutrition services such as 
enteral and parenteral nutrition in (feeding through tubes and veins) 
institutional as well as hcoa settings. But here, too, other 
professionals, such as pharmacists, ccnpete %iith dietitians to provide 
services. Rirthermore, the aging of the population and incxeasei 
hospitalization of patients with ccj^plex problems requiring nutritional 
intervention d»ild stimulate demand. Another iaportant tpward pressure cn 
demand is the unriwtftl vedua placsod on nutrition. For exanple, the 
fitness novanent includes oonscicusness of the iufxartanoe of good 
nutrition in health pranoticn and dismfie p re v e nt ion. Grocery stares and 
magazine publiedierB cqplcy dietitians to advise on the nutritional content 



• 17 - 

TAILI 4,St Hfttf tlM' Nijor rtaett Mh and toUry b^loymt, 

Mter of Jtbi 

Muter of Jete 


Tttai li^ivyMnt 






iotplUU, puMIc 




Vurtlm and pmml 
Mft faclUtlw 



KUCIs U.S. DiporlMht of Liber, turtau of Labor Statlttlct. 190r, "C^ploywit by 
oeeiipitlQn and Ifduatry, 1966 and projoctod 2000 tltamitlvM.a Nodarota 
atttmatl¥t. CUtpubllahod.) 

Nrcvttaoat Mart ealcutatod wing itirwidad flfurtt «id iHU tffiartfort not ba 
Idantlcal to p o rcam am that ny ba eatcjlatod ualni ttit roifidid f ffuroa prevfdad 

' Total liploywn • Miga and aatanr ai^ployawnt ♦ aalf oapioy—n t . Ineludaa 2«000 
aatf*apptoya^ Morfcara In 1966 an4 2,662 In 2000 itfie ara not attaeatad by Induatry. 

- IS 

of foods and to d«vtlop x^cipm. Zhdividuals an vUlijig to 
out-^-podost for nutritlcnal ocnsultatkn avallabla through Iniepenlmb 
practltlonats or aa a packaga with othar aazvioaa. Health cara paxvidora, 
aaddng to ocnpets with each othar and attract OGnsuniers, ara Incx^aaingly 
awaza of tha iiqpartanoa ocnniDBrs ]^aoa on mtrltlonal advrioa in cabeaity 
and cholaatarbl aarth^^. Also asaociatad with disaasa prevantlon and tha 
hi^ oost of tzaatingr acuta ocanditlcna Is ttm uaa of nutrition in 
pravmting ooronazy diaaaaa. diabatas, obaaity, hiypartanaicn, 
atharoadaroaiB, and arthritis. Fto^ddara at rlak for tha ooat of caza, 
BoA as HOa, oan ba axpactad to usa nutritionists to raduoa tha 
liJoalihood of acuta illnoaa. Rdblic health ^^artaaenta alao OGnoaxntd 
with prevantin? disaasa and prcvida nutritional aandoes througjh such 
progzans as Wic« Cna suzvay identified 22 stata health agency pirqiam 
areas eoqpactad to uaa nutrition aarvioes and noted e^qpmded nutrition* 
aezvioea ksy local and state public healtti aganciia (Kaufinan at al. 1986) • 
Although public health funding is tiq(ht it appears that nev appreciation 
of the value of laitrition etzvioee is generating use. 

The aging of the population vill drive yjp denand for dieticiana to 
care for the ocnplex nutritional needa of nursing hem patients. Ihe BLS 
data reflect this in an asqpected increase of 3,600 joba in nursing honaa, 
%ihich vill increase the proportion of dietitian jobs in nursing hones from 
approodnately 14 paroent of all joba in 1986 to 17.6 peroant in 2000 (aae 

Omrall, eoployrsnt growth e}qpactations for dietitians are veil 
abovis tha national average but are nodezate to mdest \tmn coRpared 
acme other allied heedth fielda. Ihe hospital sector is not likely to be 
a major source of nev ^losmnd. Independent practitionera contracting with 
hoq;)itala and nursing hcnas do not represent new opportunities but e 
different enploynent pattezn. On the qpside, public denand for 
nutritionists^ sezvioee should cxaate sane nsv cnploynent. This vill acst 
li)cely occur in settings nariceting directly to consumers and aettinga 
%lhera the dietitians^ role in health pronotion and rtl^BMfie preventioi is 
valued. However, the increased potential for anployment in any of the^ 
sites vill create only a minor overall increase in denand. 

Following is a list of factors that are important dateminanta of 
donand for dietitians: 

o oonsuDar desire for nutritional advice 

o new places of eoployment such as the food industry and 

o rends in private practice 

o tronda in siibstitution of othar professionals (nurses, 
health educators, heme economists, pharmacists) for 

o interest in, and payment for, health prcnotioiv^diseaae 

prevention and perceptions of the isportanoa of nutrition. 



19 - 

One ^iiM aoenarlos described in Oiapter 3 have dif ferwit inDacts 
on danand for dietitians nainly throus^i their role in health ptcnotian 
and disease pntvention. 

Moderats growth of demand for nutritionist aenrioes %dU '^i r 
through aaqpansion of CBploynent opportunities czeated by ttm agina of 
the population, diract oonsuner danand for sendees, ard hospital 
adhnissions of patients with oaa^-'w pttblm. 

Soenarlo TVo — Ppamflehiy mynart: 

in this scenario althcu;^ hospital utilization of dietltlam will 
be reduoed, overall enplcynent is less affected than other allied haalth 
oooqpations that are nora dependent on hospital eoploynant. 

grcwth of HCs and managed care systens that aiphasize haalth 
poxnotion and disease prsvention, as %ittll as nazkating to oonsunan, 
will increase danand for nutritional services. R^iciani %iozking 
outside nanaged care systons will incraase their scope of senrioes and 
ai|>lcy or contract for dietetic senrioes in their offices, oonsunezs 
vill adqpt the attitude of health care providers enitasizlng wellness. 
Ttmjf are there- fore eager for nutritional sendees and inf oniaticn from 
all acuroes— food labeling, publications, independent practitioners, 

Soenario rhr^ — v^Tftm 

Policies that enhance access to care can stiaulate dietstic 
services in several ways. By relieving financial pressures caused by 
lew oocx()ancy rates, hospital danand vUl rsvivs. Hospitals will bs 
able to hire staff to provide services oomidsred marginal in times of 
fiscal constraint. Access to services for groups with 
rutritional needs, such as migrants and pregnant teenagers, will 
stinulate danand for dieticians atployed in primary car« settings. But 
the incxaoent in danand overall will be only moderate— substantially 
less than for the ooa{)ations nora tightly tied to acuta illness. 

Sucolv of DlefcitiaM 

Hiere are three major ways of beoaning a registered dietitian. 
Orm is to graduate from a baccalaureate program in an appropriate field 
of stud^ and ccnplets an internship, ths second is to conplets a 
graduate program in diatstics. Because interchips ara in short sisply 
(only abait 900 per year oonpared with appraximately 3,000 students who 
need internships) , 3one graduates of dietetic programs do not proceed to 
registry. Ohirdly, othen ciroaivant the inturnhip requiranait by 
ocnpletlng graduate fi i r/i ees that do not requln internships, and proceed 
to registration via that route, coordinated undergraduate progrns 
ocBbine acadanic ooursework with about 1000 houn of clinical 


20 - 

Sinn 1980 tht rudaer of newly-registerad dietitiam has tUlm 20 
perooit, txm just ovsr 3,000 to just under 2,400 (Aaarican Dl«t«tlfi 
Assoclstion, 1987). ^ 

Thm ocnsansus for ths past tm years is that then has bem « 
aixplus of dietetic professionals (American Dietetic Association, 1935) 
Ihls ocnduslon tfuuld only be tentatively ncxUf led by the salary iraiaa^ 
of 29 percent between 1981 and 1986 received by dletltlrm eiployed in 
ho^ltals— an increase ocspanble to that of phannaclstM and staff nines 
v«)o are perceived to be in short siqpply (UDS, 1981 and 1986) . Because no 
other evldeinoe of shortage or surplus was found it is j*ft««twv< that a 
reasonable balanoe exists today. 


Zf the nunber of nsv registrants per year is naintained at artiurd 
the 1986 level of 2,400, or if only a very scdest decline occurs, the 
ooomittee estimates that supply and donand for dietitians will be in 
balance \q) to 2000. 

Hcwever, halting the decline in registratiora will regulxe both that 
aadanic prograns remain viable and that health care and educators act 
aggresively. E^loyers need to offer jobs as attractive as their 
oracKtitoTB for dietitians outside the health care Industry, as veil as 
making dietetics as attractive as other possible careen. However, it ijs 
not aliAys possible to dlsoem differences in scne of the jobs that 
registered dietitians hold anJ jobs held by other types of dietary 
personnel such as nonreglstered graduates of dietetic p myx anw and 
graduates of hcne eooncndcs or food service management prograis. It is 
possible that these latter gra^ will be used in greater nunten if 
eiployen find it difficult to hin registered dietitiam. 

Dnergency Medical Technicians 
Dsoand for Bnergency Medical Technlciara 

As it does for other fields, ths Bureau of labor Statistics 
in the case of Ztergency Medical Tachnicl»ns (EMTs) estisates the nater 
of paid jobs. Because emergency medical tedionolgy jobs an often filled 

volunteen— by a ntio of 2 to 1 in 1984— tte BIS stresses that its 
estimates cover only paid SOS. 

BLS eotlmates that then wen 65,000 paid EMTs in 1986, a nail 
nmtier of iJhaa had received the advanced training and field CMperienoe 
recjpiired to beccme an EMT-EtaBmedic. Ihe BIS data exclude volunteen aitl 
do not distinguish among ths three levels of BOu, Hm lower (basic) 
level EMT-A and the i^^per level QfT-P have eodsted sinoe the late 1970s. 


m 1981 an InUmndiata level (QOVZ) %iBa added to the ovalldbla 
oartif ications (HdQ^y, 198!^) . By 2000 tht nadaar of paid QOu la ^^^^ ^ 
to incraaaa ky 15 pttovit to 75,000.- Ihla growth ia auiastantially balov 
that of othar alllad haUth f ialda dianwiwd in thla ch^ptar and balov tha 
oqpactad 19 patoant growth in tha total U.S. labor foroa. BIB notas that 
thia alow gitwth in anploynent vill ba ahapad by conflicting foccM. On 
ona hand, populatuxn growth, e^»cially tha Txrqportion of aldarly, is 
oqpactad to iqpur donand for EMm. Ftcqeeas in «nargency nedicina is alao 
asqpactad to incxeasa demand. Gn tha cthar hand, tha rising cost of 
training and aqoipnent ooqplad idth tha taminaticn of federal startip 
ftinds for ocniunity cnazgen^ nedical aaivioea, tasqpayer resistanoa to 
incraased local govazment as^ianditurea, and tha availability of unpaid 
vbluntaazs ara factors liJcaly to constrain job growth for paid EMXte 
(Bureau of Zsbor Statistics, 1986) . 

Of tha 10,000 BCr jobs aaqpectad ty tha BIS, stats aid local 
goverrsient vill aooount for alnost 40 percent (sea Ihbla 4.4) . It has 
been noted aneodotally that tha govamnents of najor Bstropditan areas 
throughout the Uhited States have been examining existing emergency 
nedical services and ccntrastlng tha benefits of contractual aervicas 
versus govemnent-zun aarvioes. Decisions to use contractual services 
vill of course lessen the e}qpected growth of jobs vithin gcvemnent, but 
OKferall demand tftould not ba nuch affected by a change in ofaoyar. 

Ihere also appears to be no v en a n t towards privatization of S6 
aervices. Along vith large ccnpanies providing aervices on a contractual 
basis, there has been growth in physician-owned anbulanoa aervices and 
prlvately^run energency departments that operate their own aDbulanoa 
service. The BIS foreseea 2,400 new EMT jobs available in privately-owned 
anbulancae aervices— nearly a quarter of all newly created jobs. 

Ihe BLB predicts that hoepital esnidoyinent of QflS %dll increase by 
11 percent. Ihis is based on a determination that hospitals, es^ecting 
emergency nedical aervices (Q6) to be profitaUe, vill conpete vith 
private anbulanoe services. But anecdotal evidence suggests that no trend 
towards hospital-managed IMS is developing. Ohouc^ some hospitals havs 
been entering tha market, others have tested it and stepped away. 
However, there is evidence (also anecdotal) that SOS ara acmetimes 
enployed in hoepital emergency departments— the nurse shortaga being a 
major factor in decisions to eqplcy Qfm (MciQiy, 1985) . 

The BLB projection does not differentiate between jobs for the basic 
OCT versus the more highly trained paramedic, but tha availability of 
volunteers na}ces such a differentiation iiportant. Technological 
dsvelopnents have virtually transformed anbulanoes into mobile intensive 
care units enploying technician* vith Skills in defibrillation, 
endotracheal intubation, pharmacology, and other aqpecta of intensive 
care. 'Volunteer technicians are usually not adequately trained to 


.1 1^6 

mit 4.4t terimy MIcal tadmlclm' MJor Pltcm of Wig* wri Salary ei^loyMnt. 
19M and 2000 rrajactdd 

(Jim juuu 

Total faploywit^ iS.lOO 


Total IHh ft Salary 

E^loymi 100.O 79,000 100.0 
Local and Intarurban 

^•^•t 3f.2 27.W0 S7.I 
Otato and loeal 

•^^f^^rm^^ 24.900 S7.ft lf,700 99.6 
Noa^tala, pMU 

andprl^oto U,dOO 12.4 U,aOO 21.7 

WJWIt U.t. DtpartMit of Liber, lurtau of Labor Statfatfea. 1W. "Eiploywnt bf 
occvpotlOT ind fnduitry, 1906 ind projactod 2000 iltimitfvoa.* Modarato 
altomatlvi* (UrpiMIM.) 

^ Hrcvitagai Mara oaloilatad ualno iiuwidad ffouroa «d nf U tharaforo not bo 
tdintteai to parcantaoaa tfiat nay ba caloilatad uafnf tho roifidid f ffuroo provfdad 


Doii not tneluda lovarfMnt hoipftiU ind a.^a. 

Total l^oywit ■ Mfo and aalary wployMnt ♦ aolf aaployMnt. 



KBcqpdaUly aMtm that l«ml of cax« (Staith and Bodai, 1985) . As thi 
UM Of advanoid Ufa afipoort tadnlqiMS baoona aoca oomoridaoa, denani 
ftr pazwBdloa is likaly to incxeaaa ihazply talativa to othar lavals of 
anrgancy wdical tadvdcians. Valuntaar tadniclans typically hav* only 
baaio txaining and so pcovida littla or no ocqpetitlon for jdas xaqairing 
advanoad aldlls. Hauavar, tha icMar Isval basic^MT seeking a job misw 
oopata with tha voluntsar. 

Xncxaasad dantrnd for the basic SfT can ba aaqpectad ftaB tha 
non-natgancy tLane^ioctation aactor. C3na oonsequenoa of Medicara's 
piDoqpactiva paynnt ^ysta has bean tha aarly dlachazge of elderly 
patimta. Patients still in need of nuxsin^ care are often trai^nrtad in 
mtxHjuam to nuraing hcnes. EMT-basics aza oployed cara for the 
patients in txanait. 

Sifply of Ztergency Kadical Tp'-hnicians 

Etergency nedioal technicianr era trained in a variety of settirgs. 
AocrttUted aduoetional pa ; ogiami for EMT-FuraDedics caDe into being in 1982 
and hava graduated a total of 2,466 Bfr-hraniadics thicus(h tha 1985/86 
aradmic yiaar (Oonqtittaa on Allied Health BAication and Accreditation, 
Allied Health Blucation Directory, 1984, 1986, 1987r Journal of tha 
Ansrican Itodiaal Association, Sepbenbar 1983, Septenbar 1984, Septadaar 
1985) . A greater nnbar of pa r a m sdies are trained in isiaocradited 
prograiBS. Aooording to tha National Ssgistzy of EKTi, there vara 440 
BfT-Iteanadle training pi t igiaBS in 1985, of «Adch only 15 vara 
•ocreditad. lha 1985 National EMS Dat. Suanary lists a total of 5,059 
Bfr-PBraDedics being trained annually, only 42 states and tha District of 
OolUDbla xai^pcnded to the survey. Ihraa large states'-<alifamia, Nstf 
Yooic and lyntas— vara rst r -»g those reporting riguras. Ihus, the nmber 
of QCr-Xtaanedic graduatea is substantially higher than 5,059. lha aana 
survey showi a total of 83,650 basic QCDi being tralred anrually (National 
SS Clearing Houae, 1985) . 

Observers of the field aay that paranedicB are in very ehoct 
su(^y. The opport^'if :y cost of training and rapid buzncut disocuragas 
entry into the field. 

Ihera Is very rapid turnover anong DCDi. The average volunteer is 
active for only five to six years (Zueaah, 1983). lha tumcKmi> rata ancng 
full'^tiae eaployed SITi is said to range b e t w ee n 20 and 40 percent. 

Ihe ocnmittee vas i:ku£trated by the lack of reliable data on tha 
basic ctiaracteristics of the EKT vorkforoe and foroes that influence their 
training and use. Ihese appear to vary anong OGBDritifls, and are also 

24 • 

changing rapidly. ?Bds fl«ld cNenpllf !«■ thm pcdaXans of trying 
pradict tha Mart in tht ab8«no» of « t«ll organized professlonBl 
aasoclatlon that o6Ilacts, or stlnulatav dta ooUecticn of aarpoMar 
InfonatiGn. Ihla lade alao aakaa it itaem difficult for BL5 to aaka a 
uaaAd oooqpatlonal claaalf ioatlon. 

laddn^ data on nohara and tranda ir ^ Ijiing of BfF-XteaDtdlca and 
Basic EKnp, ^ is iapoasibla to aaka an wnffOMmnnt of Aitura trends in tha 
balanoa t Mm siqpply and danand. Andaty about tha quality of cnargancy 
aarvioas has aurfaoad in aona cities. Should this anxiaty apraad, denand 
for Bora hic^y ttaintd individuals oouxd put piesaura on tha siffily 
pipalinas. Data ooUaction oould halp clarify facts that dacision-sakarB 
naad to aneiura tha raooth luming of enargency medical aenrloes. As 
iH-t i i iii Hi i WI in Chapter 2, an interagency tadc foroa oould «iork towaxda a 
data collection plan. 

Madlcal AdninistxatoTB and Tadmicians 

Donand for Madlcal Raoord Technicians 

The BL5 projects that the ruuber of jobs for medical record 
technicians will grow by 75 percent from 39,900 in 1986 to 69,800 in 
2000. This rapixl growth exceeds the rate predicted for an/ of the other 
allied health fields atudled in this report, esecept for pi^lcal thenqpy. 
unfortunately. ECS does not aaJca a projection for floplcynent of im>^<^ 1I 
raoord admlnlstratora. lha eoqpectatlon of rapid grcvth in jdas for 
oedical raoord technicians is predicated on the incraaslng iTi|»rtanaa of 
tt» nedical recorda function in financial oantrOl and billing. JUS 
analysts ballevia that ttdm hi^ rata of growth is liXaly becauae heilth 
care payen era requiring tore detailed and accurate nedical raoords fdr 
nlx±urBenent puxposea in all aettings, including outpatient, m the 
past, nan/ jobs in mwUnwl raoord dq>artinants and physician of ficea ware 
filled by indl>riduals trained on the job to perfom coding and 
transcription ta^. But, incraaslng payer demands have raised tha 
ocnplexity of work so that staff trained cn the job ara no longer 
adequata. Ihus, a surge in denand for oertified technicians is expected.^ 

This analysis can be suflbstantiatad to a great extant. Data fron tha 
American Hoepltal Association ahow that atploynient in U.S. reglstarad 
oamunlty hospitals of nedical record technicians grew by 6 peroant in the 
two yeara fbllowing tha introduction of VfS, ocnpared with 2.5 peroant in 
the two earlier years (American Hospital Association, 1985 and 1987). 
Employment of tha mora hi^y-quallfiad madlcal raoord admlnistratars 
expanded by ?.l percent in both the two yeara befora and tha two years 
after FFS. :;:.« /oDerlcan Medical Record Association (AMRA) stuiied the 
iiipact of FI>s» on a sanp*a of 775 hoapltal medical record departxants. 



Stud^ findings noted that 93 pexxaent of raepcnlents agreed that 
proipectiv* payment ragaixed gxaater mp&rtiBB, and 75 peroent noted more 
atiiii i| Hiit hiring standaxds (Schxaf fenboger 1987) . Another AMRA study 
attritoutss at least acme of the daserved increases in naobers of ODiplcyees 
and aaJa r i e s to advent of FPS (Bernstein, 1985) . Miether this 
translates into hiring mcxre credantialed practitlcners is not stated, but 
another AMRA survey noted that a "substantial perooifcage" of departments 
filled coding positions sxclusjvely with credentialled professionals 
(ItiiUodc and ftiitBore, 1987) . 

Although ttiB ispoct of FFS is one factor in accelerating teaixl lor 
medical recxaxto tectoricians, the role of medical records in utilization 
revriev and quality control most also be nobad. Ihe con|>lexity of medical 
records eystcns that interface with utilization and quality review systons 
and with piVBician office lihkages, raises the required skill standards as 
%«ell as generating increased demand for p e r sciuwl. 

Automation of medica:'. records departments has been occurring fast. 
In 1981, 28.3 peroent of hoepitals saofiled by Shared Data Research had 
send autcmation. Ey 1984 this figure had risen to 48.1 percent (Packer, 
1985) . IMoubtadly the cloee connection between the medical record, 
billing, and cash flow encourages automation in order to qpeed p*«yments. 
The questions of whether, and if so vAten, the use of oonpt^ers v Jl slow 
dcMn the denand for medical records technicians is not clear. However, 
retention of the paper medical record appears to be ccranon, because 
oonputer technology cannot oonpletely substitute. For exanple a p^t pe r 
record is needed if li1:igation occurs. 

Ev official attenpts to siiplify medical record tasks seem to 
backfire, da UB-82 form, an attcnpt to create a fonn that all payers 
could use, served only to increase the workload for coders and has 
resulted in the hiring of additional staff (Burda, 1984) . 

m 1984, about three-quarters of all wmliral record technician' 
jobs twre in hoepitale. HhB pattern of cnployment is changing and BLS 
esipects that it will oontiiwa to change. By 1986 only 61.5 peroent of all 
jobs were in hoepitals. By 2000 the BLS eoqpects hoepital enploymoxt to 
have fallen to about 58 peroent, and enplcynent in out-patient facilities 
to have risen fton 9 peroent in 1986 to almost 13 percent in 2000. 
Ihcreased demand from non-hoepital health care providers is eo^sected to 
rise for many of the same reasons as denand fton hoepitals is rising. 
Payers' doaanentation requirements are increasing for all settings and 
document a tion for billing purposes is tied to i^ira l records. 

- 26 - 

In mm, cknond for qioalifiod mer'acal reoard peracnnel is related to 
the annxnt and eqphistlcatlon of r^iized doc u mant a tlon for putpoooo that 
Include raitfsuzMnent of eervioes, na^pcactioe protection and quality of 
care OGRsiderations. Ihe ongping changes in reirixTreaient policies, with 
pa^Bcs increasingly oonoemad vith ap p i qpiL i ate utilization of services, 
will continue to g en e r at e stead/ increases in denand for medical records 
perscnne] • Bckmmr, the rate of increase is likely to slov as record 
systens beccme better establidied. Thus, ttie greatest increase %iould 
occur at the beginning of the period. Ite ELS estimate of a major (75 
percent) overall increase in denand to the year 2000 is sqpported by the 
eoqpansicrjory forces at work. 

Fnr those looking to the future, iiqportant factors to monitor 

o chinges in payment systens and regulation 

o growth of new cnployment c|:pQrtunities in out-of- 

ho^ital settings 
o iiqpact of autooation 

o nsw uses of infc^3natiGn contained in medical records. 

Ihe three financing driven scenarios described in ChagitBr 3 have 
direct miA siiqple iiqplications for the denoand for medical records 
technici;jns. Ihe qpread of procpective payn^vrt stisulates demand as the 
amount and ocmflBxitf of documentation tied to payment increases, and 
facilities use the medical record to rrvif^ utilization as a part of cost 
control efforts. Denand in the myxisa Bomaucio increases in proportion to 
the amount of increased service generatixi. 

Donand for Medical Services Administrators 

BecBuee the BIS does not project demand for medical ^record 
^administrators we do not have an estimate of 2000 cnployment. Ihe nunfcer 
of persons with a bachelor degree in medical record administration is 
relatively enall (approximately 9,500 people have graduated with the 
credential since 1970) (Otainiittee on Allied Health Education and 
Accreditation, Allied Health Education Directory, 1979-87; Journal of the 
American Hedical Association, ^^^itaiter 1984; Septenfaer 1982; Septenter 
1981; Oouncil on Hedical Kl^iioaticn of the American Medical Association, 
AUied Medical Education Diractory, 1978, 1972-74). It i£> difficult to 
determine how enployars view the difference between the more hig^y 
educates? adtadnistrator and the technician. Roughly half the directors of 
medical reccsd departmenti; have the administrator credential, and half are 
registered teclmicians (Am'^tayaJoil, 1987) . Itien medical record 
techniaiiyis are dep aitx aai L directors it canned be gueseed lyhether this 
occurs because administraton are not available or because they are too 
expensive, or because technical level skills are adegjate for this vatk. 
Given this uncertainty, it ie not possible to discuss dif ferenoes in 
future denand for medicil xcoord administrators and medical record 



- 27 - 

The Sqpply of MBdixsal Raoard Persomel 

Although gradttatlcra of both medioBl reoord adhninistratorB and 
oedical rwxocd tedmicians have inczeased sinoe 1980—20 peztsent for 
adhninisttatan, 27 percent for technlclans-^the iixzease dnun fay 
tedmieianB has been steadier. Together the two types of programs 
prodjoed aloost 2,000 graduates in 1986, of which about 46 peroent were at 
the adninistratar level. Ohe nnbeac of aoczedited technicdan 
grew rapidly in the late 1970b. Today there are 87 prograns, but the last 
six years pcoduoed only 7 peroent of thn (Gtnnittee on Allied Health 
Education and Aoczeditation, 1987a) . Seme schools have closed, in part 
because of a decline in the applicant pool and in part because of budget 
pcdblcns and accreditation zeqaixenents (Oonnittee cn Allied Health 
Education and Aocxeditatiofi, 1987b) . 

Graduates of aocxeditad ptujiaiuB do not represent the to ol si^fdy 
of vorkezB to fill jobs in nedical record departments. Substantial 
nuDbers of eoployers vho "ccnpile and maintain nedical records'* (the ELS 
job description) are trained on the job to do transcription and other 
tasks for i^hich extensive training is not necessary. 

Assessing %hether there is currently a good balance between si^y 
and deeend for nedical reoord administrators and technicians is 
conplicated fay the availability of WDrkera %ho can be trained to fill the 
less skiUed jobs if necessary. It seeas unlikely that widespread r^xxrts 
of job vaca n cies will occur if eni»lc^ ar8 can cdKiei i tLg te their xise of 
skilled practitioners vhere needed, and fill in with others. However, the 
findings of one salary survey, suggest that cnplayerB nay be struggling to 
fill jobs with qualified practitioners. Between 1981 and 1986, the 
starting salary for nedical record adhniniatrators in hospitals increased 
fay 45 percent— substantially hic^ier titan an/ of 19 other types of 
hospital eqployees. Hadical record technicians did less well (possibly 
because they re vore available or po& Jtily because they are nore 
vulnerable o substitution) . Iheir gain was 24 peroent, an increase 
exnwKte d fay half the group of hospital enployees (UDCB, 1985 and 1987) . 


If one assutned that graduates ficon accredited schools were the only 
source of nedical record technicians and that deoiand would grow at the 
rapid rate predicted fay the BIS to the year 2000, there would not be 
enough trained technicians to fill the jobs. However, these assunptioie 
are not realistic. We offer then merely as a starting place traa yitdxh we 
will indicate how the labor narket is likely to work. First, workers who 
have not had the benefit of accredited education do fill 'obs in swxiical 
record depai-taents and will continue to do so to sane extent. However, 

• 28 - 

current tmds indicate that the knoi^ledgie and skill level needed in 
nadical xeoords is rising, and will oontinie to rise in the foreseeable 
future. Iterefbre a greater proportian of trained poractiticnfirB %dll be 
naeded to fill ourxent and nav jobs. Gfc^iations o2 administrators and 
technicians are en a rising trend and the naber of aoczedited p rogi di u s is 
qrcwing, albeit slowly, ttiJ^ it is likely that the sqpply of trained 
technioians vlll gicw n ot veoain constant as in cur initial assuoption. 
In flUB, to ovoid a dxartage of aedical record personnel to the year 2000, 
the labor sartet wst nake aajor adjustnents that will cause medical 
mord tedndogy to be viewed as a acre premising career than it is 
tuiay. one likely change is that the investment in medical record 
edhmtlGn idll be reoofydted in greater pay, status, and tadc 
dif feruitiatiGn— and tiiere are indications that this is already 
happening. As this happens the nmter of specially trained workers 
iAx3Uld grow, enaibling oniaoyerB to continue to phase out those with only 
on-the-job training. 

Occupational Ihereqpists 

Denand for Oocqpational ahereqpists 

Ihe BL£ estimates that jobs for occupational therapists will 
increase by 52 percent between 1986 and 2000, txxMSL 29,300 jobs to 44,600. 
Ihis predicted hic^ growth rate is Icwsr than that predicted for physical 
therapists in part beause a greater proportion of oocqpational therapists 
are enployed ky the slow growing education sector. Jost over 36 percent 
of ocaqpational therapy jobs were in hospitals in 1986, and 13.2 percent 
were in gcn/emnent eafdoyment (excluding education institutions and 
hoepitals) . Four^^and-a-^ialf percent of jobs wer^ classified by BIS as in 
""bf f ices of dther practiticners^^—that is offices of practitionere other 
rhan physicians (including osteopaths) and dentists, and includes the 
offices or independent practice occupational therapists, (see Table 4.5) . 

ELS analysts identified a nunber of factors eoqpected to drive this 
predicted strong growth in cnployment. Ihese factore Include occipational 
therapists increasing their share of hospital cnployment; federal 
legislation concerning services for handicapped children increasing 
aqployment in school service, and increases in private practice 
opportunities stimulated by iiqproved reimbureement. 

Ihese factore will undoubtedly stiiailate demand for oociqpational 
thenpists. Hospitals provide over one-third of available jobs today and 
the growth rate in this sector will have an isportant influence on demand 
for ocaqpationzd therapists. Oca9>ational th^rsqpy is one of the fev 
allied health groqps that sustained enploynent growth in the two years 
after the introduction of HPS. FTB enployment in U.S. raqistered 
h «pitals increased by 10.7 percent between 1981 and 1983, and by 22.7 
percent between 1983 and 1986 (American Hospital Association, 1985, 1987, 


V f 



and 1988). Scne of this growth in hoepital aii>lqyinent is ti» result of 
mn hospitals offering coopational therapy services. Betojeen 1980 and 
1983. 25 hospitals added oooqpaticnal thwapy to their list of 8«vioes, 
imd k 1984^Sv«y of ho^ital ODs indicated that 18 percent ganned to 
add or eniand ooooational thersgpy services. (American Ooaiaticnal 
BrawjSsociation, 1985). Despite this history ^straig jjwth, 
mSS^oca«ational theraR' can lie c«»tabliAed as enhancing the early 
Sschaige^pBtimSs, the service coLld be vulnerable to aits if hoepital 
operating Bargins continue to ba threatemf. 

Houever, demand fdr ocaiational therapists in prolonging the 
indepemenoe of AIDS patients, could in the future, generate deoiand for 
BcseoaaBational thBr!a>ists. Ihe role of ocoqpational therapy in caring 
for thaiiSntally sicik and in such settings as half-way hcuses can only be 
inferxed ftoa the BIS data. Psychiatric hospitals and psyddatric units 
of general hospitals are included in ttoe hospital in dustry estimates, and 
ocozntional therepy services often are provided by contractors to, for 
exanple, halfH*ay hcuses. However, occajpational therapy has a long 
SStory as part of the team caring for people with mental illness, future 
demand from this sector of the health care system will be determined by 
nental health insurance coverage, the availability of publicly sponsored 
pcograns and tJie evolution of treatment modalities ftor mental illness. 

Itiat ta»B data do not Aow is the extent to %iiich eqploymanl gnwth 
was sustained by the use of occqpational therapists in ho^tal based 
rehabilitation facilities, which have not come under PSS. According to 
the Jtoerican Occmational Dierapy Associatian's 1986 menter wrvey, 
rouAly 40 percent of hoepital enployment was in rehabilitation (American 
Occupational Oherapy Association, 1987) . Demand for ocaiational 
tit^ists in rehabilitation care is being stiaulated by two factors. One 
is the discharge of patients ftxm the acute care hoepital to 
rehabilitation facilities to escape the PPS setting. The second, 
effective Jldy 1987, is the addition of occupational therapy as a Medicare 
covered rehabilitation agency service under Part B of the Medicare 
regulations (Scott, 1987). 

Medicare has mie other changes that will stimulate danand for 
ooaaational therapists. Since July 1987 ooopational theraRr has been 
oov^ lay MBdicare Part B for service in skilled nursing facilities. 
Ihis provision will allow billing of Medicare for ooapational therapy 
services and will provide a new incentive for therapists to establish 
practices marketing to nursing homes. 

Hone health care represents vwther area of potential growth In 
demand for oocipaticnal therapists. The nunber of ocaiational therapists 
cnplqyed ty certified agencies rose from 410 in 1983 to 3,979 in 1985 and 



TAiLE 4.5: Occi^tionil Ttitripista' Hijor Plactt of Itogt and Salary Qiploywnt, 
19B6 and 2000 Projactad 

Mmbar of Joba 



Niflbar of Joba 


Total EnployMHt^ 



Total yaot I Salary 





Hoapitala, pi^lic 
and privatt 





Outpatiant car« 





Officat of fnysiciana 





Off feat of othar 
hlth practitionara^ 





Education inttitu- 
tlona, privata and 





Fadaral, stata, and 

local govarrMnt 





SOJRCE: u.f . OapartMnt of labor, luraau of Labor Statiatica. 1987. "Eii|>loynent by 
oco^iation and Industry, 1966 and projactad 2000 altamatfvM.« Nodarata 
al tamat i va. (Unpii>l lahad. ) 

Ptrcantagaa Mart ealculatad uaino trrounded figuraa and will tharefort not ba 
Idantical to parcantagaa that nay ba ealculatad ualr« tha rouKlad figuraa providad 


Total E^loymnt > naoa and aalary aaploywant ♦ aalf a^ployMnt. Includaa 3,000 
aalf-aiployad uorkara In 1966 and 4,6U In 2000 Oio art not allocatad by Infcjatry. 

' Offleta of hMlth practltlonara otNr than physicians (Includlr^ r^taopatha) and 
dantlata. includts offlcaa of aalf-aiployad occifMtlonal thtr^lata. 

^ Doas not Includt c^^vtmaant hotpltala and achoola. 



- 31 - 

dxqpped to 1,997 In 1986 (National Asaocdation for Hone Gaze, 1987) . In 
viw of the iqpwazd pressures iti donand far oooq^tional therapy senrices 
in the hone it nnntw lilcely that acne of the 'W^n^*^ is due to incxeased 
oontzacting for oooqpaticnal therapy aervioes. 

m 1986 nstf federal legislation (Rjblic law 99-457) was enacted that 
should increase dewmd for ocxa^atlonal therapists Iby the educational 
sector. This legislation increased federal funds to encxurage state 
departnents of education to pcoidde special education and related services 
to handicapped preschoolers. Ocxupational therapy would be available to 
children }dho need it in ctrder to benefit fron special education (American 
Occqpational Therapy Association, 1986a) . 

Other factocB tending to generate denand for oocipational thers^ists 
are related to desngraphic and disease chuiges. Oisse include increased 
survival of head trauma victias and low birth weight neonates, m 1973 no 
CT Bpc n de nt to a survey by the Aosrican Oocupational Ihen^ Association 
reported head injury as being among the nost fteguently seen probleiB. By 
1986 3.3 percent reported head injuries as seen most frequently. 
Similarly, developmental disabilities (excluding mental retardation) rose 
fron 5.8 percent in 1978 to 16.5 percent in 1986 as the most fkequently 
seen problen (American Ooopational Qierapy Association, 1985; American 
Ooa|3ational aheraEy Association, 1987) . ihe aging of the papulation has 
ixoplications for greater use of ooopational thengpy in nursing hones, 
hone care, and hospitals. ;i:t is estimated that about 17 percent of 
occupational therapy %rork is with elderly patients, and that large nunbers 
of nursing heme residents would benefit if oop:^ticnal thezi^ were 
available (National Institute on Aging, 1987) . But significant irjczeases 
in the role of occqpational therapy in nursing heme care are unliJoely 
unless financing bec o mes more generous, or regulatiom rec|uire it. 

Some disease patterns and financing moves should geneinte downward 
pressures on denand for oocupational therapists. For eoeanple, the 
incidenoe of cardiac diswiHe and oerebro^vascular accidents (whose 
Baryela e are aooinonly treated by occupational thenqpist) is declining- 
althoug(h this will be r Jset to soma extent by increased survival rates. 
On the financing side, efficiency incentives and oonpetition are eo^iecbed 
to continue to force facility managers to jeek ways to reduce costs. 
Oocupational theraqpists may be asked to incxease productivity anVor say 
be vulnerable to reductions in enploiynent by nanagexB seelcing to trim 

In sum, the vpMod pressures on denand for ooa^iational therapists 
are eoqpe c ted to cxoood and amnlhelm downward pressures. Growth in denand 
will be greater outside the acute care hospital sector and should be 
sufficient to be of the order of magnitude predicted by BL5. One 
uncertainty which could substantially decrease denand J.n the future is 
Medicare paymert for rehabilitation services. Miile eocteraion of FFS on a 
diagnosis basis in rehabilitation is unliJoely, seme sort of incentives for 
ecoranic restraint are slated for introduction. 



TBc±arB that dxxild be ncnitored lay thoaa interes^ifid in assessing 
denand for ooovoticnal therapists induSe: 

o Hadicsaxe payment and xegulatiGns for rehabilitation services 

o groiith of the hoapital sector 

o dauogr aE iiics cxxKieming school age childroi, and 

pr ogr a m s for handioBE{)ed children 
o participation of bam care and dt!ksr longr-^term care services 
o the roles aaqpeting oocqpations such as recreational 


Our tbcBa scenarios reflecting three different health care funding 
environments affect denand for ocaqpational therapists mainly through the 
iapact on ho^ital care. 

Scenario One — Mixed model 

Uti ^ scenario foresees contiruation of most trends in evidence 
today. OeBDand for ooopational therapists to vork in hoGpital& and 
rehcd^ilitation facilities continues to increase steadily, assuming that 
the latter remain free of PBS. Denand ftan ddlled nursing f^cdlities and 
hoae care agencies also shov modest but steady growth as more older people 
need service. 

Scenario 1%k> - ProsDectlvB Payaent 

The financial incentives incorparated in this prospective payment 
scenario create dounuord pressures on demand for occupational thereqpists. 
Uhder this scenario managers in general hospitals will scrutinize cost 
effectiveness studies for evidenoe that occupational ttyBop^ decreases 
length of stay, and is cost effective. Similarly, large eeoployers will 
include occupational therapy in benefits pedcages if it is shoun that it 
speeds return to work. Laddng such evidenoe, growth in acute care 
rK)qpital and outpatient cnployment will be negligible. Rehabilitation 
facilities, also %xarking under prospective payment, will reduoe demand for 
all types of personnel. 

NOrsing hemes and home care agencies will increase their demand for 
occupational therapists but this will not offset the drcp in denand traa 
the ho^ital sector. Independent practice will thrive as consumb«.B seek 
services that are no longer available to then from institutions striving 
to reduce costs » 

SoenariQ Ihr^ ~ lif?mff 

Ihe surge in denand for medical care generated fay a policy of 
increased access to care will stimulate denand for ocaqpaticnal 
therapists, providing that rehabilitation services for newly entitled 

o 146- 


groups vill lnoc a L pata ted into new benefits padcagtfu Qrthqpedic 
pctbLmm that ni^ have remained untreated far lack of fUndUng can be 
oared for. Rehabilitation services needed after the acute phase of trauma 
or strJce oan be poravided. Keurdioapped individuals will have gcxxl 
to oooqpational therapy services bqfond their school years. If such 
grcqps as hcmeless pecple gain access to care, and mental health coverage 
is eoqpanded, demand fbr oocupaticnal theraqpists will be increased. 

SqppLy of Oocqpational Therapists 

For the pest decade the njubear of ocaqpaticnal therapy graduates has 
fluctuated ttm year to year but has averaged around 2,000 for the last 
two years. After several years of stagnation in the 1980s, the nmber of 
aocradited prograiiB recently juqped fkcm 56 in 1985 to 63 in 1986 
(Oomnittee on Allied Haalth Bdocaticn and Accreditation, 1987a) . ihis 
surge appears to have outstripped the availability of fUU-time faculty, 
forcing pr o g r a n s to rely increasingly on part-^time faculty (American 
Occupational Therapy Association, 1985) . lUrtharacre, f ielduork placenent 
of student is beccndng more difficult. Education progr an s reported 424 
facilities cancelling placements in 1984/85. This figure had risen to 625 
in 1985/86. The most fkequently cited reason for cancellation vas loss of 
occupational thenqpy staff (American Ooccpational Therapy Association, 

The comnittee heard persistent reports of enployers' difficulties in 
recruiting ooaqpational therapists especially for rehabilitation 
facilities. These reports are substantiated by the tm enployer surveys 
that exist (Veterans Administration, 1987; Horth Carolina Area Health 
Education Oenters Program, 1987b) . 

Also supporting the notion that occupational therapists are in short 
si;pply is vhe finding of a survey that starting salaries of occupational 
thereqpists in hoqpitals increased 31 percent between 1981 and 1986. This 
is ccnparable to 30 percent for pharrocists and 27 percent for staff 
nurses ^iho are generally felt to be in short supply (UDGB, 1985 and 
1987) . These indicators of a ti^|ht labor market are generated from the 
health care sector. Whether enployers in other secbars are also having 
trouble hiring occupational therapists is not known. Nor is it known 
whether the opportunities for enployment outside the health care sector 
might not be causing the health care enployer's probleins. 


Assiming that through the year 2000 the education sector is unable 
to reqpond to increased demand because of faculty ahortages, ve expect, to 
see health care Mployers making some adjustments that use the existing 
labor force more effectively and encourage extended tenure and return to 

- 34 - 

the labor fOroe. Such adjustments ara litely to include laprovanants in 
ptokictivlty, cutting use of occupational than^ in that han/e the 
least effact on patient caze, and raising salaries. If faculty can be 
racxuited to allov education utoyiaas to aaqpand, eaployers vill have to 
make adjustanents to attzect people into cazeers in occqpatlcnal then^. 
Ohus, to aaintain a balance in supply and donand it vill take both salary 
and WDcldng condition iaprovenents to bring in students, as well as 
« w pw n ded eduoation capacity to pnpare the students for tte voaypluod. if 
the SBzloBt far acne reason— such as health care facilities being unable to 
afford salary increases—fails to nake sufficient adjustments, a shoortage 
of ccofational therapists is likely. 

R^sical Therapists and Assistants 

Demand for Rtysical Therapists and Assistants 

Ihe BUS eo^ects growth in the nariber of jobs availedale to physical 
therapists to eaeoeed growth in all other allied health occupations. 
Between 1986 and 2000, 53,500 new jobs are predicted, representing an 
increase of over 87 percent from 61,200 jobs to 114,700 jobs. Ihis 
prediction is based on an eoqpectation of nq;>id growth in aeveral 
aettings. In the hospital the push to thorter statys is to 
incxease danand for then^ists. The move to hone care is ea^ected to 
increase demand for piiQvical l^ierapists in that setting. And the 
attractions of indqiandent practice are es^jected to centime to draw 

Although all the major settings in «hich physical therapists work 
are expected to eoqierienae substantial increases in denend, it is notable 
that enployment in "offices of other t^th practitioners" (that is, 
offices of health practitioners other than physiciats and dentists) will 
grew nearly threefold (adding over 25,000 jobs) to beoone the najor 
eeploymant setti ng for physical therapists with almost 35 percent of all 
joias. Ey contrast, ho^ital aiployment will grow atbout 43 percent, ackiing 
8,500 jobs, but by 2000 will provide only 27 percent of jobs conpared to 
the 35.5 percent share it had in 1986 (see Table 4.6) . However, some of 
the then^ists imrking in th<« "off io^s of other health practitioners" 
will be supplying service tt) hospitals and other health care facilities on 
a contractual basis. 

Ihe BL5 eaqpects demand for physical ther^y assistantn to i.^nease 
by 82 percent between 1986 and 2000 to 65,000. Ihe similarity of tl^ rate 
of grcwth for this group of practitioners to the predicted grwL) rate for 
physical therapists is due to the EOCf analysts determination that the same 
factors drive demand fbr the two groups, ftyers can have significant 
inpact on the use of assistant level practitionus, however. GOnnants 
made during the connittee's site visits to hcjepital pi^ical therapy 


- 35 - 

(tapartanents Mntlcrad that limited use tns nde of assistants because of 
Madioara x«]uimnts that physical therapists perf ocn the regular 
•valuaticra naadad tx> doostttt progress, ihis is felt to liadt the 
usefulness of assistants so ^t their CBployment is curtailed. Ihysical 
ttecapists, thnsslves, hsvs been relictant to aDoploy assistants. 

There Is suiostantial sfport fbr the assiaptions made by ELS aoout 
growOi in desiand for physical therapists. QilDce the level of ho^ital 
cniiloyBBnt of aost other allied health occupations, hoepital atployment of 
physical therapists was not raducad in the years inadiately follawlng the 
introdkiction of K6. Rather, M^OoyBsnt of ft^Bioal therapists ocntinied 
to grew increasing by 5.3 percoit betMMn 1983 and 1985. (taarican 
Hospital Association, 1985 and 1987) . Other svidense supports the idea 
^t pre has not served to redooe the use of physical therapy in 
hoqdtals. A stud^ of seven acute care hospitals in one county indicated 
that refeKrals of Hedicare patients to boQi iiintiant and outpatient 
physical therapy incceasad after the introduction of HGs. ihe 
iaiaication dram fkon this study is that physical therapy is seen as an 
effective and efficient txeatnent that can help to rehabilitate patients 
within tins and econcndc constraints (Dora, 1987) . Hoepital cnploynent is 
also being sustained by the eoqpension of hoepital rehabilitation 
facilities and by the incxeasing intensity of care needed by irpatients. 
Since xehadailltaticn facilities are exrsluded frcn fFS these units are used 
to f&cilitate discharges to the less rastrained pe^mant enviroment. 

Ihe Anerican Riysical Iherapy Association (1987a) reported that 
therapists in hone health incxeased their hours of service and that denand 
for services in nursing homas increased. In 1983, there were 
413raodnately 1,700 physical therapists enployed fay Medicare certified 
home health agencies. An additional 2,155 provided contract services in 
the hone. Ey 1985 the nuniaer of tfaen^tists aployed in such agencies had 
increased to 6,685 and dropped only sli^iUy to 6,234 in 1986 (American 
Health care Association, 1987) . 

Ihe novenent of patients out of the hoepital to hone heal^, nursing 
hones, and rehabilitation facilities represents a change in location of 
services ratho: than an increase in egploynent. However, scne factors are 
generating an increase in cnploynent in all settings. One such factor is 
physicians' and the public's perception of the need for physical therapy. 
Rnctitioners note that physician perception of the value of physical 
therapy services sustains the level of referrals at the sane tine as 
patient danam for ther^jy, especially for ^lorts-related injuries, is at 
an all tine high. 

Ihis latter reason is one of the factors enabling physical 
tiienqpists to practice independently. Aooording to a survey by the 
American Riysical Iheraqpy Association, between 1978 and 1983 the nuoDber of 
8elf-«i{)loyed physical therapists iixzeased fron 10.0 percent to 14.6 



- 36 - 

TABLE 4.6: Hirtfcat Thtrapfttt' Nijer Plactt of U^t and SaUry Eipleyittnt, 
1986 and 2000 ^rojactad 

r of iotas mmbt of 

1966 Ptrcant^ 2000 Ptrcant^ 

Total Ei^loymnt^ 61,200 1U,700 
Total tfagt & Salary 

EiployMnt 56,200 100.0 105,400 100.0 
Nospftals, pUMfc 

and private 19,900 35.5 28,400 26.9 

Offfcaa of physicians 3,300 5.8 4,900 4.6 
Offfcaa of other hlth 

practftfoners^ 11,500 20.4 36,600 34.7 
Outpatient care 

faculties 3,000 5.3 6,500 6.2 

SOURCE: U.t. DepartMnt of Libor, 8ureau of Labor Itstfstfcs. 1967. "E^ployntnt bf 
eccMpatfon and Industry, 1986 and projected 2000 sltemtfves." Noderste 
altematf v<a. (UnpUbl f shed. ) 

^ Percentages Mere celculated usino urafidsd ffguree end Mill therefore not be 
Idmtfcsl to percentegee that s«y be celculated usfna the roinded figures provfdsd 

^ Total Eaploywnt « wage and salary s^ployMint ♦ self enploynent. Includes 5,000 
aelf-e^ploysd iiorkere in 1986 end 9,300 In 2000 Oio are not al located bf Industry. 

^ Off IcH of heelth practfoners other than physfcfsns (fnctudine osteopaths) and 
dmti^ts. Includss offices of physical theriplsts. 



pnoant of fUll-tiae therapists. HcMever, since 1983 thl.^ has cnly 
incvaaaad to 15.8 peaxaent. part-tJbae self Mcxlqynant ttans a similar 
pattern, gicwing from 4.3 peroent to 6.6 peroent of CBopX^yaent between 
1978 and 1983; and nprasenting 7.7 peroent of enplpynenL in 1987 
(Ajuerioan Rvsioal Biierapy Awociation, 1987b) . ftwther this rr dueled 
growth res ul ts fccn lack of growth in daooand for ttm services of 
indepmdant ponK^itianers, cr lade of ijiterast in that farm of practioe is 
not knoun. Bqpially liloBly is that the rata of growth in indepeniait 
pcactioe will pick vp again. Mcsraover, these self-anplcynbnt figures do 
not r^i t M M iit the whole picture of independent practioe. Sme then^ists 
work for the profarietars of ind' ^ proctioes. In 1987 24.2 pextaoit 
of reapcndent s to the Anerican k v 3^ Therapy Associaticn's survey said 
that thi/ WQckad in a private phyiLiOwil ^wrapy office. Ihis figure 
r^fxtedtdv Includas the 17 -9 peroent who said ttey were owners, partners or 
proeident >f a practioe or tauslnass (American Riysical Ihenqpy 
Aaociaticn, 1387b). 

Wiile sens therapists in private practice have ccntracted to sa?ply 
hoepital services, others have thriving ractioes to which physicians 
refer patients cr patients (in seme std^^) refer thenselves. Ohus, 
thoapists are able to benef^ ■ directly trm public percepticn of the 
value of their services. Ocr^ttee site vists shewed tha«- even in man^ied 
care systons, where utJlizaUcn car be oontcoUed, oanagers note diat 
peticnt dsaand for ph^cal then^ is pushing them to eo^and 
services— end in a coniratitive enviroraiBnt managers are reqxmive to 
patient danond. last, but not least, as a factor generatijig growth in 
denand fbr physical therapists, is the aging of the {npulation. Elderly 
peq^ae need a greater vdune and intensi^ of service to treat their 
aultiple pcdalens. Sixty-seven percent of physir " therapists rB|.jrt that 
patients 64 and older are puct of their patient pupulaticn cn a typical 
day (Amsrloan Ihysical Ihecapy Associaticn, 1987b) . Denand from this 
iufxrtant sector can only increase. Seme care of the increasing niinberB 
of elderly patients will take place in their hemes, ihe lower 
productivity of physical therapists whr must travel to clients, as cpposed 
to providing services in health carci facilities, will further stimulate 
demand for practitioners. 

Ihe availability of financing of physical therapy services should 
allow those changes to translate into eharply inczeased denand for 
therqpists. Financing for physical ttvsrsp^ services is relatively 
svailetble. insurers and enplcyers hove recognized the role of phyi xced 
therzqpy in enabling people to return to work or preventing 
institutionalization in expensive settings. Oonnercial irsurers often 
cover the service. Mbcker's Oonpensation p rogram s cover auch of the 
eoqpensit fcr testing and therapeutic treatanents by physical then^ists. 
mcreaaed sensitivity to long-^term costs has stiaulated anployers to cover 
the rehabilitation of warkers and pay for injury prevention prograns in 
the inckplaoe. Medicare covers hone visits fay physical therqpists and 
physical tiierapy services in inpatient and outpatient sdccinge and has not 
yet placed rehabilitation facilities under any kind of. proqaective 


ERIC .1 

Ztr a oonl»iii0tim of aary facton should gensrat* strong 
inc CTMM in donand fbr Fhysioal thanqpists. OSw cnly focasaeable najor 
ciiange is the introducticn lay MKllcani of a iyston of paynmt for 
t^rtiabilitation aarvioM ooitai ling an inomtive to aoanGniza or ration 
•rtvioas. If tha past pattam of hoe^ital staffing in raeporae to ISG 
tmaara, cvan this inomtiva aay not nduoe dananl for pttysixal thanmy 

Ttands that ara i a pot tai it to the future of donand for physical 
therapists and ihcAild La Banltorad include: 

o growth of hospital care 

o physician and public valuation of services 

o changes in rahtdoilitation reiaburaenant ani 

o peroqptions of affectivenass in facilitating early discharge 

ttm ho^itals, early return to work, ani in previonting injury 

in the wariq>lace. 

Ohe mjar role cf financing in generating denand for physical thera- 
pists is reflected in reqpcnse of denand to the three soenarics 
described ^ Chapter 3. A downturn in danand is not foreseen in any 

With a continuation of several financing systems existing side by 
side, denand for physical thsrapists will be high. Oomnercial insurers 
%rlll pay independent practiticners and allow them to B^*:ve patients %ftio 
increasingly want care fbr apada injuries, lower bade pain and other 
diagnoses treatable on an outpatient basis. Hcsepital use a£ physical 
therapists is stimlated by the admission of older sidoer patients who 
need services and fay facilitation of earlier di^koge. Outpatient use 
Inczaases, too, as financing continues to be available in all settings. 
DBBopening demand, hcMever, is an Increasing effort on the part of lOA and 
other tliird parties to devise more stringent reiiiburBenant scxaens as a 
means of constraining growing utilization. 

SoeniiT-in Tun- 'Vr^Bp^^yp Pf^YHmt 

Kith proepective payment the predominant form of financing, denand 
fc£ physical therapists will be scnewhat lower than under the nixed 
paynent nodel. Iherapists in independent practice %dll feel the iapadt as 
they are faroed either to join a aanaged care s^stm or to laly on 
patients' willingness to pay for services out-cf-podoet. Bicihasis on case 
BBnagenent, utilization ocxitrol, and cost effectiveness will zadkioe the 
rata of growth in demand for therapy services as physiciam and 
aanagers become selective about services. FraveA effectiveness %dll 
became increasingly laiwrtant, and, until a body of reeoaiUi beocnas 
available to prove effectivenees, denand for acne therapeutic nodalities 

39 - 

Dmvi for physical then^ists will receive an added iapecus if 
aocsaac to cars is incnased. Non-acute proialanB and preventive services 
such as for.' bade pain, aiscle stzeir, arthritis, and csteoparcsis that 
wait unattondad in the absence of reislxDMient %dll bring navly^f inanoed 
patisnts into tiie iwdical care ayBteni. Ddadniahed need to cxoss-subsldize 
services for indigent patients will relieve ecne financial pressures on 
hospitals allowing a little llg^xtenin, of productivity pressures aixt 
greater reepcnsivaness to patients' doDund for physical thenpists. 

Supply of Riysical OSierapists 

Graduations from aocxedited baccalaureate, masters, and certificate 
prograns in phyvical therapy increased by 43 percent between 1979>1980 and 
1984-85 to reach 3,499 in the latter year. Ohe growth in the last year of 
that period, however, was only two p^oent (American Riysical Oherapy 
Association, 1987d) . This reduced rate of growth should not be 
inberpceted as evidence of a drop in student interest. Rather, one dean 
described physical theriqpy p iog iai iB as the "hottest spot on canpus." A 
study conducted for the Health Resources and Services Administration shows 
that there is pressure on pto g rams to eo^and their nunter of students. 
HowBver, finding clinical sites for training may be slowing eaqaaision 
(Mathonatioa, 1987). 

Although ocnpetition for therapists is encouraging hoepitals to 
ocntinue or start training affiliations in order to ease their recruitment 
problflns, they also are concerned about the costs, preferring more 
advanced students who regoire less sipervision and are more productive. 
Itatly because hospitals are rel\ic':ant to provide training, and partly to 
introduce students to the practice sites in which they are liJcely to be 
cnployad, more non-hoepital settings are being used for clinical training 
(Msthenatica, 1987) . m the future constraints on growth in the simply of 
physical tharepists are more liJoely to rise fkcmi proislenB in finling 
qualified faculty and training sites than fkan lack of stulent danand. 

currently, facilities trying to hire physical therapists are finding 
it very di .'icult. For the jJtnle period of the study the ccnmittee heaitl 
more reports of pressure in the labor martet for physical therapists than 
for any other allied health grcnp. Often it appears that hoepital 
recruitment difficulties are due to the iwibility of institutions to 
ccnpete with the earnings avzdlable to rmrapists in other settings or 
private practice. A scdution is scnetimes found in contracting for 
ptw&ical ther^ services, m these cases there is not a "shortage" in 
thy sense of then^ists not being available at a price tlid facility is 
willing to pay, but "stress" in the sense of facilities having to alter 
their way of operating to acccnnodate the changing marteet. 


- 40 - 

Ite sense of acuta istortage that the oconittAe heard tn many 
SGuroee (includling xtepnaentativoB of national or^anizatlGns, irihlch 
sugigeete that this ves not verely a local phflranencn) is nqpportad by seme 
adb&ittedly limited evidflnoe. Statevids surveys of Horth Carolina health 
care facilities reported an aljaost doubling of the vacancy rate for staff 
physical therapists ttm 13.8 peroent in 1981 to 26.9 percent in 1986. 
Vacancies for assistants van than doubled froa 8 percent to 20 percent 
(Nbrth Carolina Area Haalth Bdboaticn Centers Kcgram, 1987c) . 'Jiese 1986 
vacancy rates vere hi^^ than the rate for five of the six other allied 
health fields surveyed. Only ocoqpational ttmaspa had a hic(her vacancy 
rate at 25.1 percent in 1986 (North Carolina Area Health Education Centers 
Kogram, 1987c). 


If tte education system continues to produce physical therapists at 
the oirrent rate and the labor force behavior of tfaeriqpists does not 
change, some major adjustanents will have to occur to prevent a shortage of 
physical then^pists to the year 2000. Shortages affect different parts of 
the health care system differently. Sectors that pay more or have more 
attractive voridng oonditicra are likely to feel the ispact less. Sectors 
uraible to hire a sufficient naaber of thersq;>ists because they cannot 
outbid the hi^^ter payers, will be forced to reduce services. Ihis could 
czeate an access psnblen for seme patients— probably those in need of 
longrterm rehabilitatdon services and elderly people. 

Ihe needed market adjustments are likely to be made by both the 
education and enploymmt sectors, with enployers leading the way because 
they are the first to feel the iiqpact of ti^ labor marioets. Since 
student interest in a physical theraf^y career is already hig^her than 
educational cs^pacity can accomnodate, salary increases will not be the 
most effective wey of bringing new people into physical therapy. However, 
more pay should be elective in drawing back into the labor force those 
who have left, and in encouraging practitioners to remain active. 
Salaries are likely to incrrase and hoq)itals and other enployers are 
expected to seek more productive and effective ways of enploying 
ther^ists, and reduce their demand som»itot. E)ctended tenure in the 
labor market ehould contribute to the needed adjustment. As salaries 
rise, and if independent practice and professional growth opportunities 
increaF>a, practitlonerB can be expected to remain in the labor force 
longer and return more readily after le&vir^r* Changes of this sort make 
major contributions to relieving labor market stresses. 

Enployers concerne d with enhancing the supply of physical therapists 
iftKuld begin to understand that the costs of partic^ting in the clinical 
ccu |xjiwit of education p rogr a m s will outwel^ the costs of ad^tasting to 
both lower levels of pi^ical therapy use and the major salary increases 
needed to attract thniqpists. If this and other adjustments occur. 



gradkiatieni will «v«ntually inxesse, and, as the siqpply of new therz^ists 
pwpon ds to denand, ttia rate of salary Incxease will abate and a balance 
iMtueen dnand and Mpply wiU be found. 

If, as aone dasire, a oaster-level degree becxmes the entxy level 
xegoixonent the sinply of new pcactiticns would be wan ocnstrained. 
Itiether raising the entry level degree would also incxease salanas amf! 
reduae dennd for therapists is a topic of contention. 8cne say that 
hidier levels of professional training raqoire greater ooqpensation for 
the greater educaationBl investment and are thereby lihked to higfher costs 
(tf care, and analler aBcurits of care in tines of cost aantaimtent 
(BB>dng^Mrst, 1987) . But the Jtmerioan Rvsical aheraiy Association 
believes this axgunant is wrong for sevetral zeaEvns; noce edumtfd 
practitioner* ar* won likely to work ixvkpendanUy with fees that axe no 
hi^ier than charges neiifwiiftl by institutions that esiilGy therapists— and 
even if ttierapists weire aotre hiig^y paid, ttm cost of a $3,000 salary 
increase to fUll-tine salaried {hysical therapists in hospitals would 
l ei iLes en t less than half of one percent at the average annual increase in 
hospital care expenditurv (American Rxysical Ihereqpy Association, 1987c) . 

Radiologic Technologists & Technicians 

Denand fdr Radiologic Technologists and Technicians 

me BCS estimates that between 1986 <ind the year 2000 the nxAxac of 
jobs for radiologic technologists and technicians will grow by 65 percent, 
tron 115,000 to 190,000. Ihis hic*^ rate of growth is sinilf > that 
mpBdtBA tar dental bygienists and it eaooeeds the eacpected j / growth for 
dietitiars, apooch-language pathologists and audiologists, and 
occupational ttma^atB. Jdbe for nurdear nedicine technologists, who are 
excluded from the BLS definition at radiologic technoLoglsts and 
technician, axe expected to increase by nearly 23 percent, from 9,700 to 

Ihe BUS analysts evaluate job opportunities in the many different 
jcbs enocqpassed in radiology. These include sonogR0v# fluoroscopy, 
BBniDograptv, oonputerized tcnogrzqphy, magnetic resonance imaging and 
radiation thenqpy. TWo of the more Bpecielized fields with distinct 
accxeditaticn for educational pr ogr a ms include radiation therapy and 

In addition to analyzing the proepect s for each specialty, the BLS 
analyzes growth of jobs in differoit settings— predicting increasing 
cnployiKss: Opportunities in non hoepital settings such as pt^ician 
offices (where 27.4 percent were uiployed in 1986 ar almost 38 percent 
are eiqpected to be oplayed in 200j) , »Db, and imaging centers. 

- 42 

Hospitals aze toSay the mjor aiployaxs of zadiologic tectoologlsts 
and tadnieiam, aiwlyiiig a little owr 6^ peroent of available jote (see 
Table 4.7) . Htm VLB pradicts that by 2000 only 48 peroant of jobs will be 
in hoqpitals. Ihis does not waen, hemN&r, that the ruabmr of hospital 
jobs will ftOl— only that the rate of incxease in hoqpitals will be below 
tt» rate of job growth in other settings, indeed, the m£ eoqpects the 
naijer of hospital jobs to incxease Ir/ 21,400 fkan 70,200 in 1986 to 
91,6^0 in 2000. A sJailar pattem iA pradictad for nuclear medicine 
technologists (sse Mble 4.8) . The ctange under FPS of irpatient 
radiciiogy dqpaztMants fixn revenue center to cost oentcar, and increased 
use of utilisation review was epqaected to result in reduoed use of 
ancillai/ ssrvioas, eapecially diagnostic iaagin? (Steinberg, 1985) . Ihe 
pre- and post-KS eapkynent pattem in hospitals aipr izs to offer 
equivocal ac^ppaet for this notion. 

Aooording to KSk data, enployiDent of x-ray technologists, radiation 
thervy techncdogists and nuclear nedicine technologists dedi^ between 
1983 and 1985, oonpared with the years 1981-1983 when enplovinent had risen 
or been doee to stable. For other radiologic peraomel eaploynent had 
been falling before FFS, but the rate slowed after FFS (Aoserican Hospital 




TAIL! 4.7; Radiologic TodmolosUts' and Tochnlclm' Nijor Plaeot of Utge and Salary 
Caploywnt. 1966 and 2000 Projactad 

mmbT of Jote 


Nuiter of Ma 


Total Eiployannt^ 



Total Uaoa I Salary 





Noapltala. pi^lfc 
and prl¥itt 





Outpatltnt cara 





Offlcaa of phytfclant 





Offlcaa of dvitlau 





Off Icoa of othar 
haalth practltlcnara 





SOURCE: U.S. DipartMnt of Labor. Buraau of Labor Statlatlca. 1987. "Eii|>lotmnt by 
occupation and industry. 1966 and projactad 2000 altarrMtlvaa." Nodarata 
altomatfva. (Unpii>l1thad.) 

^ Parcantagat ware calculatad using is>roi«ided figuraa and Mill tharafora not ba 
fdtfitlcal to parcantagaa that wy ba calculatad using tha roundad figurta provldad 

Total Ewploy w n t ■ naga and aalary aaploynant ♦ aalf asploywit. Includat 1,000 
aalf-asploysd workara In 1966 and 1,900 In 2000 yho ara not allocatad fay Industry. 




TAIU 4.8: NucImt Ntdlcint TtdmolofUts' Major of Mot ind teUry 

EiployMnt, 1986 ind 2000 Projtctod 

of Jobs Nuiter of . „ 

1986 Mrcont^ 2000 Poreont^ 

Total EiployMnt^ 9,700 11,900 
Total Uaga ft Salary 

biployMnt 9,700 100.0 9,700 100.0 
Noapltals, piiblfc 

and prfvata 3,600 88.6 10,000 63.9 
Nadfcal and dintal 

laba 500 5.2 700 6.1 

Off fcaa of phyalcfana 400 4.1 800 6.6 

SOURCE: M.S. OapartMht of labor, Suraau of Labor Statfatfca. 1967. •^loyntnt by 
occupation and fnduatry, 1986 and projactad 2000 altamtlvaa." Nodarata 
altematfva. (Unpi^lfshad.) 

^ Parcanvagaa vara calculatad Mine iiiroiffKltd figuraa and will tharafora not ba 
idintf^!il to parcantaoaa that wy ba calculatad using tha romdad figuraa provided 

^ Total EnployMent • waga and aalary aii|>lo>«itnt ♦ salf anploywant. Salf-anployad 
paiaona ara not allocated by Industry. 

ERLC ^^"^ 

45 - 

Associertion, 1985 and 1987) . It is difficult to ascertain exactly jJhat 
changes are oocurrin?. In a 1985 survey of luclear nadicine department 
diractora, aAninistmtoLB, or chief technologists, 20 peroent of the 
issiiiMliiiitFi leportad a declire in the mnber of niclear medicine 
tadnblogiBts aq^lcyed, 65 percent reported a dacxease in ijpatient volume 
and 58 p ercen t reported an increase in outpetient volune. These data were 
intecpreted as resulting fron lowered ad&issions, physicians ordering 
fewer testa and routine testing ^lifting to the outpatient setting 
(Qnicitti and BBflpas, 1986) . 

A ■am widely based 1985 survey of hoepital radiology tsy the American 
Hospital Radiology Adninistrators (Oonuay, 1985) asked tdiether volume had 
increased, decreased, or renained stable in 33 per xdures. Over 40 
percent of reepondente reported decreases in three types of prooedures 
including dcull and gastrointestinal inaging. Ey oontraett over 40 peroent 
of reeponlBnta reported increases in 17 prooedjies including varicus 
flurosoopy studies, cardiac catheberization, cardiac ultrasound, various 
cr studies and radiotherapy treatxnents. The overall findings echoed those 
of the nuclear nedicine survey with 66 p eroen t reporting a decrease in 
inpatient workload and increases in outpatient clinic and private 
wDckloads reported by 44 and 57 peroent of respcndenta respectively. 
Radiology services appear to reflect a generally oisserved pattern of post 
WS utilixatian~<3eclining dramatically in tiie two years after FPS was 
introduoed and turning up again in 1985 and 1986. Fhctors that linit 
further staffing reductions include increased severity of illness, reduced 
opportunity to Aift the patient to an outpatient setting, and less 
opportunity to out umeoessary services (nraepecti^ e rciyment Annonrnwint 
Oonmission, 1987) . Looking to the future the aging population and its 
need for more intensive care together with the existing upward trends in 
radiologic uszKfe point to continued increases in demand for radiologic 

The types of personnel liJcely to be in demand in the future depend to 
scne extent on technological changes. However, it is difficult to 
estimate the ispact and rate of such changes. The eme i rgenoe of new 
imaging modalities such as MRI and positron emission tcnograptiy or, going 
back to the l97(te, the new ajrplication of ocnpiitffr technology to imaging, 
has generated major isprovecents in diagnostic cqabilities. The new 
technologies have not always sitplanted the old, rather the new imaging 
procedures often are used after more custanary work is inconclusive. The 
new imaging technologies are labor intensive. Scanning procedures are 
■ere time ooraimdng than film x-rays. Iftiether the rate of diffusion of 
future new imaging modalities will be as great as in the past is an open 
question. Foyers have an interest in controlling the spread of esqpensive 
innovation. Many will renentier attaipts to limit the nuniaers of CT 
aachines throucfh oertif icate-of-need review. Today facilities will be 
more reluctant to buy expensive equifnent unless it is believed to be 
cost-effective or repreeenta a si^iif icant inprovenent in patient care. 



- 46 - 

BqployBent outside the hospital la eaqpected to be an inczeasing 
fiouroe of dBoandl fior radiologic tachnlcianB ani technologists. 
Rnee-etanSing iaaging centers, started lay physicians developing a "niche" 
in the health care sarkat, ar» alr«ad/ sem as luring technologists away 
fccn hoepitals. RCs and gnxp practice are providing cn-slte radiology. 
Riysicians increasingly provide x-ray cegpebility in their offices. 
Althcugh in sobb states nonlionsed personnel oay operate x-xay egu^nent 
In lew vokae settixqs, in others only llcsnsed persofnel my do so. 
indeed, licensing pcovisions %rill be a significant fteoe influencing 
denand for radiologic personnel. For exaiiple, in scne states anbulatory 
care centers %Aiich hire personnel to carry out two fUnctiora lust hire 
licenoed x-ray technicians rattwr tiian laboratory technicians to provide 
both x-ray and lab services because provision of x-ray services regaires 
that a licmed technician operate the eqaipoaent. A ooanltteie site visit 
revealed that nsvly enacted licensing laus generated a sharp qpurt in 
demand for technicians vhen licensed pereocnel had to be hired to replace 
unlicensed pereomel. As a result, even an enployer «ho was %dlling to 
offer substantially increased pay was unable to attract job applicants. 

Another foroe tiiat could sustain a hic(h level of deoand for 
radiologic personnel is public Icnawledge and valuation of x-ny 
procedures. Madia attention to imaging has developed public nfff>Bfir^if=nogg 
— and this together with physician appreciation of the available 
diagnostic capabilities should ensure that denand is sustained. Ihus, 
donographic trends, technological trends in hospital care as well as 
outpatient care, and other forces will ocnbine to contlme sustained high 
demand for radiologic occiqpations. Ihe BIS* estimated 65 percent increase 
in jobs to 2000 seons reasonable. 

Ihose interested in tracking future deoand for radiologic technicians 
and technologists should monitor the following factors: 

o hoepital utilization - gq^ecially intensity of care and ca se mix 
o growth of all types of free-standing facilities 
o licensure changes 

o technological changes lUcely to cause new areas of specialization 
o results of technology assessaent. 

Althouc(h recent financing changes have had less iapact on radiology 
than seme expected, the financing changes envisioned in our three 
scenarios described in OM^Jter 3 could have a narked effect. 

Overall growth in the health care soctor, faster growth in outpatient 
care, and public and physician e^spreclritlon of diagnostic iinaging conisine 
to generate prolonged growth in denand for radiologic techniciaie and 



finwvirln TVo ~ PmepaptlVB PBYHr* 

TSm rate of growth of denand for radiologic technicians and 
tadmblogists in hoqpitals will slow as atMssiora fall but intensity of 
care increaaes for an oldsr and sidoer patient pcpulaticn. Ihe use of 
iaaging as an aid to speed/ diagnosis and spss±j discharge will be 
enoauraged. Donand fircB outpatient setting %dll increase, both fran a 
transfer of prooedures cut of hospitals and frcn an increasis in 
free-standing facilities, m all settings productivity pressures squeeze 

Ocnpetitive pressures will f oroe managers of mnnngprt care systoos to 
sedathe most productive sites for radiologic referral. HocpiteOs and 
imaging oentezs will limit staff in onier to price services oonpetitively. 

Scenario Three - Aonesa 

Because imaging of cne sort or another is used in almost all types of 
health oara— primary througfh tertiazy—end by mary medical specialties, 
the increased use of health services that would result trm a policy to 
inprove acoGSs would inevitably produce increased utilization of radiology 
services. Even if such a policy is acocnpanied by utilization controls, 
such as case aanagement, it is difficult to believe that anything other 
Mian a major increase in dmard for radiologic perBonnel would occur. 

Ohe Singly ot Radiologic Technologists and 7*achnicians 

Aooonpanylng a Icng-tezn shift fron hospitalHaased to college-based 
p ro g ram s , the ninber of radiography education progr a m s has decreased 23 
percent over a ten-year period. For several years the changing location 
of ptogia '^j s did not affect the nunber of graduates substantially. But a 
sudden decline of about 15 percent in graduations has ooc ui ieJ recently 
from 7,393 in 1985 to 6,400 in 1986 (Ocmnittee ai Allied Health Education 
and Aocredit%tion, 1987a) . nds may be tl;^ result of potoitial students 
responding to fears at reduced denand generated by proqpective payment. 

'Duo smaller and newer radiologic specialties— nuclear med ic al 
technology (Mir) and radiation ther^jy technology (RIT)— a different 
pattern frcn each other. After rapid growth in the 1970s, NfT ea^erienced 
a 25 percent decline in graduationp between 1984 and 1986. By we^ of 
contrast, RTT graduations show slow but sustained growth over the past two 
decades (Ocnmittee on Allied Health Education and Accreditation, 1987a) . 

There are indications that radiologic technologists, especii^Ily those 
with wrenlftliyfld training, are finding jobs easily. Hospitals txB 
conpeting %rith free-standing eonployers for scarce personnel (Ma'chenatica, 
1987) , and the ocnnittee's site visits found sone cnplcyers unable to hire 
the staff they were seeking. Other data suggest that if enployers are 


- 48 - 

bandng a hard tia* hiring radiologic ataff thia viy be a phmcnanon of 
wry raoMit ooauiratne. A 1986 survar- '4 health facilities in North 
OuaLina npocts that the oveiFall vacancy rate for ndlologlc pexeomel at 
8 peront was very lau aewfortA to other aUied health fields — fbr 
maoflm 11.9 pe r oen b for ■adicel record adnlnistratotB and 17.9 percent 
for raq;>izatacy oara (Nortli Carolina Araa Health Ekkntion Oenters 
Itograa, 1987d). 

Finally, adding to the Ijqpressifln of a field in which eaflaxerB ans 
starting to have difficulty in hiring, is the result of a suzv^ of 
education program diractors. Hie percentage «ho believe that radiogre^tiy 
is an attractive oifxstunity increased fron 60 percent in 1981 to 89 
percent in 1987 (Rota and Bendrick, 1988) . 


Even if the decline in graduations fron radiologic educaticn programs 
is halted, strong adjustments in the labor market will be needed to avoid 
a diortage of practitioners throucfh 2000. 

Salary adjustments axe key in any strategy designed to alleviate 
labor market stresses. Salary increases can attract new entrants to the 
field, encourage the return of those «ho have left, and prolong the 
attachment to the field of these already in it. Future sufply is highly 
sensitive even to small increments in any or all of tiiese variables. 

Ohe ouanittee believes that early and significant action in this 
field is needed to forestall serious problems in the future delivery of 
health services. 

Fooislng cn salary Increases oould be particularly productive in this 
field. Although starting wilariffs are ccqpetitive, radiologic technicians 
are later less %iell mmensated than, for exanple, progranoers 
and operatcrs, and engineering technicians—fields that my be oonpetlng 
for the same students (University of Itexas Medical Branch, 1S86) . 
Education progra m directors more often believe that radiographic graduates 
are more ineqpproprlately ocnpensated Xhsan other ocnparable allied health 
graduates, exo^ those vho work in laboratories (Parks ani Hendrick, 

Health care prcwiders play a particularly iainrtant role in 
generating an adequate sqpply of radiologic personnel. Many education 
programs are hospital based, and all are heavily dependent on health care 
facilities to open clinical training cpportunitles to students. Because 
of the eoqpense of eguiiaiBnt and the iBpossibility of siulating patient 
contact, acadenic institutions lust maintain dose ties «fith clinical 
sites. Despite such costs as decreased productivity, increases in repeat 
tests, and faculty salaries, health care providers should not 
underestiaate their inportance in securing a continuous si^ly of 
personnel for theoBelves as well as other providers. 




- 49 - 

RB^ixatoxy Therapists 
Daoand for Ra^ixatory Therapists 

The ELS predicts that by 2000 there will be 75,600 jcte for 
raspiratary therapists—cm increase of 34 percent over the 56,300 jcte 
available in 1986. This growth is substantially hig^ than will occur in 
total national aDpIcyinent (19 percent) , and in sane allied health fields 
such as dinioal laboratory technologists or nuclear nadicine 
technologists. HcMsver, the growth is Boderate when oonpared with 
physical tiisrapist and aedical record technician for «bcn growth is 
SMpected to coeceed 70 percent, and occupational tiieregpists ani radiologic 
technicians and technologists for %dKn the BIS eooaects growth in jobs to 
2000 to saoseed 50 percent. 

The BIS estioate of 34 percent growth to the year 2000 is based 
largely on an afMwifwnnnt of how respiratocy thert^ists will fare in the 
hoqpital setting, ^dtyexe almost 88 percent were enployed in 1986. Althorigh 
BIS predicts only a 12.2 percent increase in overall hospital cnployment 
to the year 2000, their analysts ej^ect hospital daonnd for respiratory 
therapists to imease 25 percent because of increased MMssion of 
older and sidcer patients «ho regoire more interaive care. BL5 also sees 
denand for reqpiratary therigpy being generated by J a pro v eaents in trauna 
care that allow nore accident victims in need of ventilator care to 
survive. The developnent of small ventilators for low birth weight 
neonates is a technological factor in increasing denand for respiratory 
services in hospitals. BIS foresees increasing specialization within the 
profession as therapists become more eoqpert in such areas as neonated and 
c ard ia c care. Simoltaneously, reEpiratoocy therapists are also eo^ected to 
become nulti-oonpetent, moving into such areas as electrocardiography 
(QG) «hich i#auld allow hoepitals to curtail the eoployment of EH5 staff 
for 24 houre per day by using the already^xtesent respiratory therapists. 
Thus BLS analysts eo^ect nearly 82 percent of the 75,600 respiratory 
therapist jcfas will be in hospitals in the year 2000 (see Table 4.9) . 

The outlook for increased enploynoit of re^iratory therapists in 
heme health agencies is not viewed optimistically by the BLS analysts vAio 
e^ect reiiribursemBnt policies to prevent significant eoqpansion of heme 
care opportunities for re^iratory therapists. 

M e dicare reiatu rDanont policies for req>iratary therapy in the heme, 
under the current political and financing climate, sifport the ELS notion 
that by and large future oiplaynent will be generated mainly in 
hospitals. The services of reepiratory therapists are not reij±ursable by 
Hedicare on a per visit basis. Rather, the costs must be included in 
administrative e a g o n aoo . Thus ceploynent by home health agencies is low 
%dth the reepiratory therapist nore often retained as a consultant to 
staff making heme visits. Of 214 home health agencies surveyed, only 12 
enployed a raspir&:a(ry thenpist either as staff or as a contracted 
cxxisultant (Health Oare Financing Adodnistration, 1986b) . A recent report 
to Oongress an»«red the question of whether Medicare should es^iand 
oovera ge to inclucle respiTatory therapists' visits in the negative. The 
report noted that nurses, idho are covered on a per^isit basis, can treat 


TMU 4.9i RMplratory Thcrapfst*' Major PlacM of Wa«« and Salary E^ployMant, 
1906 and 2000 Projactad 


Of Jobs^r of Jote 

2000 r^rctnt^ 

Total EnployMnt^ 56.300 75.600 
Total Uagt ft Salary 

t^loi^t 56.300 100.0 75.000 100.0 
Noepltali. publle 

andprfvavt 49.400 87.7 61.900 81.8 
Outpatfant car* 

f«cU«tfaa 700 1.2 1.500 2.0 

Offlcaa of phyalefana 500 .9 1.100 1.5 
Offleaa of othar 

hlth practftlonara' 2.000 3.5 3.300 4.3 
Othar haalth and alUad 

haalth aarvieaa^ 3.400 6.1 7.300 9.7 

SOURCE: U.S. DapartMnt of Labor, luraau of labor statistics. 1987. "fiiployiaent by 
oco^Mtlon and Industry. 1966 and projactad 2000 altamtlvaa." Nodarata 
alt^matlva. (Unpii>l1ahad.) 

^ Parcantasas Mara ealculatad using unrouidad figuras and will tharafort not ba 
Idwttlcal to percantagas that ba ealculatad using tha romdcd figuras prov1<iad 


Total E^loyMnt • Maga and aalary a^;>loynent ♦ aalf aaployiMnt. Salf-wployad 
partona ara not al' catad by Industry. 

' Offlcas of haalth practltlonars othar than physicians (Includlr^ ostaopaths) arvl 

* Haalth sarvlcas othar than offlcas of physicians, dtntlsts and othar haalth 
practltfonars. nursing and othar parsonal cara facllltlas. hoapltals. nsdlcal and 
dsntal laboratorfas. and outpatlant facllltlaa. 


nary patimts %tio are in naed of respiratory cajnt, and can be ^)ecially 
traiml if neoessary. Little evidence vms found that hospital stays vould 
be redmed by eoqpanded payment fot* hone care sen^ioes, and althou^^ jiany 
Madicare beneficiaries can be helped by reqpiratory care, e)cisting levels 
of services %«re deemed sufficient (Health Owe Financdng Jk^ministraticn, 
1986b) . RaepisAtciry aqjilrmmt and supplies for use at hcne are covered by 
Medicare under the durable medical egoiinent benefit. E(|uipnant supply 
nmrani s B support hone patients fay hiring ^orof essicnal staff such as 
reepixatory therapists %to can sqpervise installation and undertaloe 
patient education. (Otoe American Association of Reepiratory care has 
reportedly had difficulty in tracking cnrloyment in durable medical 
eqiuipaent ccqpanies.) Deqpite perceptions that inczeasing nuoobers of 
patients could benefit trm re^iracory therapy services in their hemes 
(see for eoci. GiTnartin and Msdoe, 1986) , unless reiaburBement ciianges, 
re^intory therapists are unlikely to eoqperienoe significant increases in 
hone care %iQrk. 

A 1986 srody fay the American Association for Respiretory care 
provides tentative support f or the BL5 vim that respiratnry thera^ 
enployment in hoqpitals has the potential to ror^ at a faster nte than 
overall hospital enploymBnt, onoe productivity yains have inproved to 
their limits, x ^ association surveyed hospitals and educators to 
evaluate the iapact of WS. ihe survey found that sinoe 1983, houre of 
respiratory care services increased in over half of surveyed hospitals, 
and admissions of patients with respiretory related diagnoses stayed the 
same or inuceased in 70 percent nf hospitals. However, in re^iratory 
thera^ ^epartanents the perscnnel budgets and pnployment vere generally 
either stable or decreased (American Association for Respiretory Care, 
1986a) suggesting that inprovonents in productiv^^ oocxirrec?. 

Other changes occurring within hospitals can generate csntinued 
steady enployment grwth foi. respiratory therapists. As suggested by the 
BLS, req>iratory thereqpists are increasingly being used to provide 
nQn-re%dratory care services (American AssocLaticn for Respiratory care, 
1986bi . In cne hOEpital visited by the ccnndttee, respiratory ch^^pists 
reported expanding into cardicpulmonaiy arean such as the r^ yi^i^ 
catheterization laboratory, increasing thpir activity in hemodynamic 
mnitoring and filling in en EEXS and eervices. Ihe aging population 
is also liJcely to increase admissions c' ,>atients %iith cardicpulmonary 

Iseaae and d^function. Chronic obstructive: pulmor'^ry di fwisf* and lung 
canc?er exasplify dififtases to vihich elderly ^leople are particularly prone. 

OounterLig th ise iqpMard mcrvements are vdownward pressures that could 
oocur if reL^earr^ers and nanagere look more critical, t services. A 
1986 cJitoriiil in the New England Journal of VMcijnd (Petty, 1986) «iL;tod 
that in the shift to FPS re&piratory therapy was t^^rtfete^ **as a likely 

- 52 - 

eKBaple of undlBcipliiied practloes and iwmnooq for xsasons that Inducted 
a dearth of good aclentlfic data Gn many technlgoas in OGnmon use**. 
Noting studies itfioving evidence of the effectiveness of sane therapies, as 
%iell as one study Indioating ttj:t scmBtiines respiratory therqpy oan be 
zeduoed vithout affecting outoGoe, the editorial oorcludes with a call for 
an ij p r w ed scientific data base to guide practioe. 

Ihe extent to vhlch reepiratocy therapy is vulnerable to reduction in 
tines of constraint will depend only in part on evidence of necessity or 
effectiveness. Other inpoctant factors include an absence of patient 
demand for ti^erapy services and tiie strength of departsnent managers in 
each hoepital's hierarchy. It ves noted on a site visit that although the 
volune of respiratory thuapy has diminished outside of intensive care 
units (lOIs) because of more s trin ci tt i t utilization review and ioproved use 
of medications, simltaneously lOJ activity iias dioMn large increasefs with 
sicJoer patients needing ventilation oara. 

In simi, the BIS analysis of mcxlerate groiTth in jobs for re^iratory 
therapists is well substantiated. Hospital eqployment is the chief source 
of growth, stimlated hy the aging population and demand generated by the 
technologies that save extremely sick individuals. Cut-of-hoGpit2d 
enployuent is small and liJcely to remain so. Even a large inczease in 
non-hospital demand would have cnly a small effect on total demand for 
respiratocy therapists. 

FactOTB that will have an inportant effect on ^ v^cymsnt of 
req)iratory therapy Include: 

o hoqpital admission rates 

o severity of hospital adndssions 

o disease patt^nis, especially cardiopulmonary di 

o the outccne oi^ effectiveness studi^^s 

o the esqpansion of activities of respiratory therapistr into nev/ 

o medicare reimbursement of respiratory therapists in home care 

o esployDKit by the durable medical equipment Industry 

o eaqpanded use in nursing homes. 

Ttv last three factors can diminish the dependence of the profession 
on ho^ital eorOcyment. HoMevi^ , because an es^losion of out-of-hoepital 
eqployment is unlilcely, growth of jobs will cnntiiue at a moderate rate as 
forecasted by BL5. 

Khile the dtxAre are ^ factors that should be tractod to identify 
trends in demand for respirritory ther^ists, major financing changes, as 
cutliifid in the scenarios in Cheqpter 3, vlll also have major iapacts. 

Growth in hospital oployment will continue to be moderate, ftieled 
largely by the aging population. Dnploymmt in home care vL.1 increase 
only very sli^tly as reimbursement constrains home visits. Bqployment in 

ERiC l^C 

- 53 - 

other settings will cxntiiue tp be niniaal, so that hoepital growth will 
oveK\riheln other chemga-. 

Soenario IMo — Proeneetiva Bavment 

mcvaasad use of pcoqpective payment tdll foroe hospital 
administratocB to seek out ways of reducir? costs as hospital utilization 
falls. RBcpizatory thaxvp/ is litely to be vulnerable unless shown to aid 
in early discharge. Hoi^itals will also seek to increase their stake in 
non-hofipital nrkets to ensure that, after earlier discfiarge, patients' 
continuing care produoas revenue fbr the hospital. Hospitals will becane 
Furvcyocs of noce intensive hone care, including reepiratory there^ in 
modest anounts, Boploynent by durable nwiir^ equipment rniiiiinlffl will 
increase as the y prasri'le more intensive out-of-toepital services. 
HcMBver, ccntraction of cnplcyinent in the hospital soctor will overwhelm 
all other effects. 

Scenario Thm — fVmffP 

The greatest increase in demand for respiratory there^ists will occur 
wi^ this scenario. Hoi^ited use will be stinulated by making financing 
an/ailable fbr people «ho are today unable to dotedn such care. However, 
seme of the hcepital expansion will occur in "elective" procedures which 
are toda^ p ut l^ je J for lack of financing tintil sickness is acute. Ihese 
less acutely side patients are less intense useis of respiratcxy therapy 
services than are sicker patients. 

Si^jply of Respiratory therapists 

The characteristics of today's respiratory thcre^ workfoxtse reflect 
the multiple routes of entry into the field that have existed but are now 
disappearing. Analyses of the 1980 cersus indicate that a s: ^f icant 
proportion of the wcxdcforoe, including credentialed personnel, had only 
on-the-job training (Health Resources and Services Administration, 1984) . 
9iere now a trend toward rraining in pt uyr ams that culminate in 
certification amd/ar licensure. As a result the shorter p rajr^ m * 
providing training for the lower^level reqpiratoiy technicians are 
diminishing. Ihe nunber of accredited technician pr ograms has decxeeLsed 
by 2.3 percent, fixn 173 in 1980 to 169 in 1986. Ihe nunber of graduates 
has (tenrBa sed fay 21 percent, from 3,206 in 1980 to 2,539 Li 1986 
(wxmittee on Allied Health Education and Accreditation, 1987a) . 

Aoocnpanying the move to certified (eraonnel, qporaocship of 
educational p t ujxaius has shifted fron ho^5tals to colleges and 
universities. Camunity colleges offer tlKt greatest proportion (66 
percent) of prograns. Ihe rudber of <kxar§dited therapist prugiai i B has 
increased ty 34 percent, trxm 175 in 1980 to 235 in 1986. But the nunber 
of graduates has not shown parallel growth. Rather it has fluctuated frm 



year to year %ilth a hig(h of 3,868 in 1985 followed by a six year low of 
2,740 in 19£6 (OoniDittee on Allied Health Bducatioi and Aoaceditation, 
1987a) . Thii: Buggests that during low years excess educational capacity 
(exists. FUrthenmre, the trend in graduates bears mtching to detemine 
lAvjther the 28 peroent drap in graduates between 1985 and 1986 is other 
than an ancmaly. 

Ihe axniittee has heard ocnflicting reports of the availability of 
respiratury tharapists, suggesting that there are substantial differences 
anong local iKUiCBti>. Salary data are ^^vocal in their support of the 
notion that the labor nartast may be very tig(ht. At least two data sets 
allow ocnpariscn of the rate of salary increases among seme allied health 
professions-^the Bureau of labor Statistics' Current X^opulaticn Survey, 
and the university of Texas' National Survey of Hoepital and Madical 
School Salaries. In one of these two data sets, the salaries of 
respiratory therapists ifaowed the greatest rate of increase. In the 
other, the rate of salary increase for respiratory therapists fell in the 
bottom third vhen ocnpared vdth rates of increase for 19 other groups of 
hospital oiplqyees (Current Population Survey; IMiversity of Texas, 
Medical Branch, 1981 and 1986) . Ihese data do not allow any firm 
conclusion about the present state of the niarket for respiratory 


If tt^e ruoober of graduations fkm education p i t )gi' aius can be 
naljitained at i^prcKiAately today's level the nation's s^ly of 
respiratory therapists should be adequate for demand throucih the year 
2000. Ihis inplies that significant changes in the rate of salary growth, 
or major isprcvanents in the oonditicns of enplcyment should not be 
eaqpec^ed. To maintain this balance, education csp&citY and student 
interest must be sustained. Ihe flAX±uations in graduations suggest that 
students may need enoouragonent in the form of increased job 
attractiveness to keep up the level of interest. 

Seme caveats about the oomnittees' estimate of the balance betweei. 
simply and donani are in order. Ihe ocraoittee in eissessing future sufply 
assi.mttd that Lespiratory ther^ vcrkforoe behavior will be ocaparable to 
the workforce behavior of menbers of other there^ fields. Unlike many 
allied health fields, men represent a oAstantial pr o port ion (about 40 
peroent) ol the respiratory HiBap^ labor force. Qie signifioanoe of this 
in terms of geographic mobility, labor force attachment, or responsiveness 
. to eoonoRkic incentives—as ocnpared with fields in which almost all the 
irorkers are women — is not fully known. If jobxx remain in the labor force 
longer than mnen, the cocndttee's estimate of future scpply mey be 

er|c i«s 

ZA ocnclusicn, until better Infonnatian about ths long-tem labor 
foroe behBvior of ra^izatory then^ists is available, it is reasonable to 
believe labor mariOBtu will snoothly mate the adjustments needed to 
naintain a reasonable equilibrium between si^y and demand fnr 
reqpiratory ttierapists. However, the volatility of the nunber of 
graduaticns suc^rnts the need for close atonitaring of enezgixig eduoaticn 

Speech-Language Rtthologists and Audiologists 

Demand for Speech-language I%ttho?.ogists and Audiologists 

The BILS pfredicticns of an additional of 15,500 jobs for 
speech-language pathologists and audiologists by the year 2000 represents 
an increase fay 34 percent to 61,000 jobs. BLS estimates that 45,100 jobs 
existed in 1986 incluriing jobs in educatian that were in scne cases filled 
by individuals with baccalaureates, rather than the professional entry 
level masters degree Ihe American SP^ech-Ianguage^iearing Association 
(ASHA) estimated that 42,390 of its menbers— all of whom hold at leaSw a 
master degree— were in the active wooicforoe. Non-ASHA luniiers in the 
active wo i kf oroe, including people with only a bachelor degree, were 
estimated to nunber 41,000. Huts the association estinates a total of 
83,000 people in opooch -language and audidogy jobs— vastly higher than 
the ELS estimate of jobs. 

The growth rate to th year 2000 predicted by the BLS is similar to 
that predicted for cra;t)ational thereqpists and stems from a similar factor 
unusual among allied health practitioners— significant eo^lcyment outside 
the health ctre aysten. In 1986 only 28.6 peroent of sprach-language 
pathologists and audiologists jobs were in the health services industry. 
Sixty-four percent were in educational services— a sector in which the BL'5 
expects demand to be close to stagnant (see Table 4.10) . Betwo^n 1986 and 
2000, «)eech-language pathology and audiology jobs in the education sector 
are eaqae c ted to increase by only 14 peroent. Ihe American Sp&xtf 
Language-Clearing Association notes that 13.6 percent of qpeech-language 
pathologists and audiologists report that they run their own practice or 
are independent ocntractorB (Aip^rican S>eech-Langueige-Hearing Association, 

BIS analysts caution that their classification of speedir language 
pathologists and audiologists includes those prepared only to the bachelor 
level. OSiese practitioners are not certified by the American 
^)eech-Ianguage-Hearing A'«ociation, which certifies at the master degree 
level and above, and canr t work in the 36 states with lioeisure 
requirements. B£S analysts believe that most non- ASHA-certified 
personnel are floployed in educational services by state education 
departearts in states that certify individuals who have only a bachelor 
degree or who lade other qualifications for ASHA certification. 


There is OGnsiderable sappcart for the HLS estimates. Although 
8peecii--l«ar4uage pathologists and audiologists are provided with new 
GEfxsrtunities for growth under the 1986 Bducaticn of the Handicapped Act 
vhich increased donand ky funding p rogr a ms for young children, total 
growth of snployniBnt in education will be relatively slow. However, new 
eoployoent opportunities will occur in other settings. Speech-language 
pathologists and audidogists are well positioned to benefit fron changes 
occ ur ring in the health aystan. Iheir lesser dependence on hospital 
esfaoyment (only 10 percent of jobs in 1986) makes them less vulnerable to 
any sqiueoze on enploynent in that sector. Oheir reiinburseoent status 
positicns ther co benefit from diifts to oa^'i outside of hoGpitals. Under 
the Omibus Reconciliation Act of 1980, a epeach-langueKre pathologist may 
dervelqp a plan ot cars fbr patients referred fay a physician and be 
reiisbursed fay Hedicare. Rrlor to 1980 the amciint, duration and sccpe of 
services had to be specified fay the physician. Since 1986, speech- 
languaige pathology is among the therapies that mst together be provided 
f cr a total of ttunee hours per day for a beneficiary to be eligible for 
Hedicare coverage in the iipatient rdiabilitation facility. While this 
could provide an ispetus to increased demand for speech-language 
pathologists, it could be short lived as Hedicare seeks ways to find an 
eqioitable reinfaurseESsnt system that includes cost control incentives. 
Hedicare will also reiiBturse for home care visits~a provision that 
positions therapists to care for the growing population of patients 
discharged fton hospital or in need of long-term home care (American 
l^peech-Ianguage-Hearing Association, 1987b) . According to the Health Cbtb 
Financing Administration the estimated nmober of ^pooch-language 
pathologists enployed fay ;!?dicare certified hone care agencies grviw from 
303 in 1983 to 5,503 in 1985, but dropped to 3,113 in 1986 (American Heme 
Gare Association, 1987) . Ihe extent to which this drop is due to 
increased contracting or other arrangements is not known. Approodmately 
48 percent of trte standing home health agencies offer q)eech-language nd 
audiology services (Taisk Faroe on Home Care, IS i6) . 

Althou^ only a minority of ^seech-language pathologists and 
audiologists are enployed in hospitals, their use in that setting has not 
been negatively affected by FPS. Between 1983 and 1985 their FIE 
employment in hospitals increased fay 21 peroent fron 2,684 to 3,252. 
Oonmittee site visits uncovered several possible reasons. Ckie is expanded 
epeech and hearing coverage by »Ob. Audiology personnel vorldng in 
hoepital outpatient areas are finding that HE) patients are coiaered for 
the full range of diagnostic testing and hearing aids. Previously, 
commercial insurance subscribers had only a narrow range of hearing 
testing covered. l^)eech-language pathologists also cited growing demand 
for services for stroke and head injured patients lAiose survival rates 
have ijiproved. Audiologists noted a gromdng incidence of hearing defects 
in young people who listen to music through headE^iones. Both occupations 
cited the growing nmters of elderly patients using their services plus an 
inrreasing understanding of their services by physicians, idtdjA results in 
more numerou'i referrals. 



- 57 - 

IT. mm, speach-langiage pathology and audiology in their loajar 
■qplcynent irttlnij tt1i¥~nt t(Tin1 institutions— are not liJcely to esqprrienoe 
rapid increases in aenand. In health care settings, they are positicned 
for steady growth. IlBiib0urBenent allows them to taloe advantage of the 
flhift to non-hoq;>ital care in nany settings. Given the exp e cterl slew 
growth in eduoation, and faster growth in health care settings, the 
overall acderate growth predicted by the BLB seans reasonable. 

Ftetors to be amitored by thobe wanting tr track fixture demand for 
opeech-language petthologists and audidcgists include: 

o BBdi' nrb. reii±urBenent of rehabilitation services 
o school systens growth and financing 

o patterns of specific diweafim and txeataent such as stroke, 

head trauna and deafhess in youth 
o growth in independent practice cqportunities and contractual 

arxangenents with free-standing qpeech-language pathology and 

audiology organizations. 

The wey in lyhich the three scenarios described in Chapter 3 pl&y cut 
for epeecfo-language pathology and audiology is largely determined by the 
scattering of enplo^aent across health care settings and outside the 
health care system. 

Soenario One — Mixed Maiel 

The apeech-language pathologist and audiologist are in steady demand 
as their services are included in ccnprdiensive no benefits packages, and 
increasing nunbers are needed to work in the less productive heme care 
enviroraent. Demand in rehabilitation and outpatient services edso shows 
steady growth. 

Soenario IVd ~ Prospective Payment 

Because only a anall proportion of epeech-language pathologists and 
audiologists work in hospitals the ixpact of increased proepective payment 
in this setting has little ispact on total demand. Similarly, bringing 
rehabilitation services under prospective payment results in only a small 
reduction in overall demand. Outpatient care will ishow overall grwth, 
but qpeech-language and audiology will not benefit greatly as these 
services will be regarded as less vital than other services relating more 
directly to physical health. Less vital services %dll be most vulnerable 
to reduction under prtxpective pay<aent. Kitting togi. cher the slight 
growth in outpatient demand and the reduction in inpatient demand yields 
stagnant total demand from the health care sector virAac this soenario. 




TAIU 4.10: lpMch-Laniua9t Pattiologlttt' «id Audlologlttt' Major Plactt Mga and 
Salary l^^loyMnt, 1M6 and 2000 l^rojtctacl 


iter of <ioba 

Par cant ^ 

Nuter of Joba 


Total C^ployMnt^ 



Total Maoa ft Salary 





Education Inttftutlana, 
pi6Uc and privata 





NoapltaU, public 
and privata 





Outnatlant cMrm 





Nuralns and paraonal 
cara facilltlaa 





Offlcaa of phyalclana 





Off Icaa of othtr 
hlth practltlonara^ 





SOMCE: U.S. DapartMnt of Labor, luraiiu of Labor Statlatlca. 1987. •Ei9>loyiMnt by 
occ44)at1on and Industry, lVc6 and projactad 2000 altematlvM." fioderatr 
altamativa. (Unpi^Hahad.) 

Parcentagaa wart calculatad using irroinded ffgurta and nil I thcrtfcra not be 
Idantlcal to parcantagca that aay ba calculatad using the rotivM figures provided 


Total E^loywnt • Mage and aalary eaployMnt ♦ self saployaient. Includaa 3,000 
aelf-eaploysd Morfcers In 1966 and 4,096 in 2000 liio are not allocated by Industry. 

^ Offlcea of health practitioners other than physicians Cfnclud1f« osteopaths) and 
dsntlsts. Includes offices of salf-eaployed apeech* language pathologists «id 



- 59 - 

gcsenarlo Pirae — Aqqbss 

Qpeedi and hearing deficits axe among the group of health probleins 
likely to go unserved if individuals experienoe financial barriers to 
care. Uhder this aoenario financial barriers are lowered and previously 
igncEced OGnnunioative deficits will reoeive attention, stisulating danand 
for speech and hearing sendees in inpatient and outpatient settings. 

S^ly of ^)eech-Ianguage Pathologists and Audiologists 

In 1986 304 piogiains offered degrees in ocmiunicaticxi sciences and 
disccders. Of these 21 percent offered only undergraduate degree s . Ihe 
total nunber of ptogiaua has been quite stable ranging between 293 and 304 
sincae 1983 (CSoqper et al. 1987) . 

Ihe njBber of bachelor degrees has declined by 15 percent to 4,300 
since 1981. However, the dacline v!is confined to two years. The latest 
figures diov an upturn (C3aninittee ui Allied Health Educaticsn and 
Accreditation, 1987a). 

Ohe picture for master degrees is a little dearer. Ihe nunber of 
these dogwo awarded has remained rplatively stable since 1982. But this 
oust be viewed together with the bachelor degree graduates (GoGper et al. 
1987) . Appraxijnately 90 percent of masters degree graduates in speech 
pathology and audiology have undergp?aduate degree s in these same 
disciplines. IXxrthennare, the nunber of masters' degree graduates closely 
matches the undergraduate degrees in s p oo ch and audiology, with a two-year 
tine lag. (Cooper et al. , 1988) . Therefore ve conclude that nost 
speech-'language or ai^ology undergraduates move en to a ^eaw-language 
and audiology master degree, and that bachelor degree graduates represent 
the pool from i^ch the therapists are drawn. Thus ve must pay attenticn 
to the undergraduate as well as graduate degrees as an indicator of future 

Ihe ccnnittee is net aware of any evident ^ that si^ly and demand 
are not currently in balance. Although the ccnaittee occasionally heard 
that rehabilitation facilities vera having difficulties filling vacancies 
for spoo ch-language pathologists, they also heard that seme independent 
practitioners %iere unable to generate enoug|h business and are returning to 
anployment in facilities. Such OGranents tiiere rare and do not disturb the 
overall pictuie of an adequate current supply of practitioners. A 
national survey of starting salaries for qpoo ch^^language pathologists in 
hospitals what an increase of 23 percent betwesi 1981 and 1986. Ihis vas 
lower than the increase for 17 of 19 other ^pes of personnel. Ttist 33 
pe rcen t increase for audiologists, however, vas tdnper than that oi 
pharmacists and nurses ^to are tixxj^ to be in short supply (UQCB, 1981 
and 1986) . Ihese data indicate a difference in demand for tlie two types 
of practi' loners, but are not in themselves sufficient evidence on \tldti 
to base a jixlgpaent of the maztats. 





If baocalaureate graduations are nalntainad at appraodmtely the 
level of the last fev yeazs, and if nost of these graduates go en to 
master degree s in spaach-lanDjuage pathology or audlology, there should be 
a ocntinied balanoe between stqpply and donand to the /ear 2000. Ihis 
ilplies that slgpiificant changes in the rate of salary growth, or major 
i i q p iti v qiients in the ocxiditions of enploynent dxxild not be expected. 
However, the prodiction of baccalaureate graduates shou 5 be carefoT'ly 
nonitored. Ihe data to this tine do not indicate whether a downmrd trend 
is starting If this does oocur aqplcsyers wlx) feel the ispact of the drop 
will need to adjust to fBctors that influence people ina}dng decision about 
careers i^i lang^iage and hearing disorders. 


This dbsptsr applies the best available data to mate assessments of 
hew the forces that drive supply and demand for allied health personnel 
will iiqpact on allied health labor markets. Our indention is to alert 
decision maters to the kinds and magnitudes of martet adjustments that 
they should eoqpect and encourage in order to sustzdn a long-term balance 
between supply and demand Hcac allied health personnel. 

For some fields such as physical therapy, radiologic technology, 
medical record techn61ogy and administratis, and oocupational therapy^ we 
foresiie a need for decision maters to use the mechanions under their 
orntrol to isftrwe the working of the market so that severe iisbalanoes in 
si^ly and demand my be pre v en t ed. Sqployers are already ooncemed about 
difficulties in hiring in some of these fields, and there are signs that 
health care providers are beginning to find seme pat^nfUl as well as some 
benefical ways of aoccmnodating net/ realities. Ihe oonnittee is concerned 
that inaction may have ocnsequences that would have deleterious effects on 
the level of health care. 

For some other fields, such as clinical laboratory technology and 
dent2d "^ygiene there are factors that could cause instability in both 
supply and demand. For these fields the market is more likely to mate the 
needed adjustments aid serious disrtqptions are less liioely to occur. 
However, in both of these f ieilds there are unresolved issues oonoeming 
the match between taste and levels and ^pes of education. The way these 
issues are resolved could detemine whether major isbalances will oocur. 

Siqpply and demand for speech-language pathologists, audiclogists, 
req^iratory therapists, and dietitians are e)q)ected to be sufficiently 
well balanced for the labor market to sate smooth adjustments. Ohe kinds 
of incremental adjiistments that mate careers attractive and the ways in 
which personnel are deployed appear likely to maintain a state of 
egoilibriuD cnbc time. Hevertheless, chemges in factors we have 
identified as having major ispacts on si;t3ply and demand could cause 
diseguilibritDi. Ihese factors should be monitored. 



- 61 - 

These conclusions alxut the tatun outlook refer to the lono, tern. 
For all fields there are lUoely to be periods of graater end lesser 
iitelanoe batMMn new and the \<«ar 2000. 

It is ttt» nature of aaitets to eventually adjust to ciiange. 
Projected iidsalanoes in supply and deoand do not unan that atnrtage or 
suiplus will occur. Ratter, th^ signal that o^oyerB and potential 
mflcveee ai st, an d probably %#ill, naloe adjustanents. Only raxely do 
naxtats not aooooDodate dimgeB in supply and demand tiuxudh a variety of 
adjustaant nschaniacs. 

We have ^dontif ied areas for potential adjustment both in si^ly and 
daonand. Ihis foms a basis for understanding the fixture policy dixoctions 
oonoaming aifply and use of allied health personnel. The objective of 
policy if to aake l«s painful and cosUy the process of adjustment. 
DecEcnents In quality of care, intemqption or reducticm of service, and 
curtailaent of investment in new technologies and organizationia f onus 
(such as home care or HCs) that itig(ht inprove the efficiency of health 
care delivery are all possible byproducts of personnel shortages. Cie 
decision to intervene in tbet labor narket is made throug(h the political 
process and reflects society's willingness— or lack of willingness— to 
tolenrtu painful dislocations. In many industries such dislocations are 
viewed as nooal and acceptable, ftjblic policy actions have demoratrated 
that h ealth care is visuad differently. Ihe next three chapters of this 
report describe what educators, eo{>loyerB a id regulators, together with 
govemnent can do to facilitate sncnth woridng of the aarloet. 



- 62 - 


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- 63 - 

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- 64 - 

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Nithout steps to bo].8ter tanoKrow'e nfiply of personnel in several 
alUed health fields, health cara instituticrs %dll be hanpered in naeting 
tt» public's dannd fbr services. Ohees steps will x«c|ai£e cootdinated 
acticra by aaooators anl «i|>loyerB, anoouraged by aodest but strategic 
federal, state, and private prograns. Mary of ttm reccninenaations in this 
and th» foUcwing diaqpter are directed to eduoators, aiployers, and the 
allied health profession thenselves. Although the ccnnittee believes its 
xeccmnendatiora will be beneficial to those parties, it looks to public 
intervention to stisulate and anplify iapleoentatia 

This chapter is divided into three sections. Ihe first deals with 
pffTiH^ to influenoe the decisions of persons choosing oareers. Ihe 
second Ttinnniiiin tne role of educaticn institutions in maintaining or 
o^anding enroUments. And the third aJJuwnnn oonoems about the 
preparedness of the future %iockfaroe. 

Ohe Allied Health Student Applicant Foci 

far most fields the ar/ailable trend data on allied health programs 
and graduations do not signal an imdnent crisis regairing draaatic public 
InL-fvention. But lobklng to the future, the oomnittee is deeply 
concerned that the veak infi»8tnv3tur<s of allied healti aducation nay 
>v Tr^^°* the system's libility to naintain ann>lLiient», let alone 
inczease sifjply vhere enplcynBnt denand is hic(h. A key to the viability 
of allied health education is its ciqpacity to naintain its share of 
qualified students fkon the traditional college-aga applicant pool while 
teeing into less traditional pools of students, particularly ninority 

a nadser of years allied health deans and program directors have 
expressed oonoem about the declining nunber of applicants to their 
proLians and the inplicatiens of this dndine fbr the acadendc quality of 
the' student body. Reportadly, spaces in :ary prograns are going unfilled 
and this is jecpardizing the survival of acartmlc prograns. Goaprahensive 
data odlectian oonoeming applicants to allied health piujiaiub is not 
done. Hcuever ths Oanaittee on Allied Health Education and Accreditation 
(GAHEA) anuallx Mrveys ptugiam directors In several allied health 
fields about lAisther applications to ttair prograns are increasing^ 


decreasing, or malning stable. In its 1987 sursfey, pi txj iam directoiB in 
13 of 22 fields reported decreases in the nanber of applicants (CAHEA, 

Ihe dinicjal laboratory fields, in particular, jobtb e)qperiencing 
distress. For eNBBC>le, almost two-thirds of the nedioal technology 
y i xxp i am diractars reported dacanaases in applicants in 1987. Of the 116 
Itt og rai B S that voluntarily %dthdnw traa GAHEA aocreditaticn between 1983 
end 1987, 36 attributed their ^ion to e dadining applicant pool. 

lftf)ubliflhad survey data fran ti^ AmeriGBn Society of Allied Haalth 
I%of essicns sug^c^est that only physical thereqpy has a large applicant pool 
to drev qpon, vith about five applicants per acadendc space. Other fields 
such as dietetics, aadioal technology, radiologic technology, and nedical 
xecord administraticn average only sligfhtly aore applicants than needed to 
fill their dasaes. 

A recent survey of the Oollege of Health Dedans, an orgianization 
imposed of allied health administrative units in 20 universities without 
medical centsrs fkon 17 states, revealed that only 3 out of 17 re^cndents 
reported that all their professional classes Mere filled. Although 
clinical laboratory pi og rans vere those most ftegiiently cited as having 
exoess capacity, aany other fields also reported unfilled classes. 

Although the current level of applications vorries academic 
administrators, they are even more oono em e d about the futuri because of 
the predicted decline in the oollege agp cohort of the pcpulition, a topic 
dlenwsed in Chapter 3. This decrease suggests greater ocnpetition 
for technically-oriented students than schools are now e)qperiending. 
Inf omtLon on changing oocqpational pref erenoas ttm annual surveys of 
oollege ffceshman triKMS a slow but steady dedLie bebMen 1977 and 1985 in 
women's interest in careers in laboratory technology and dental hygiene 
(fran 3.3 percent to 1.1 percent), dietetics and hone eocnony (fron 1.1 
percent to 0.4 percent) , and health technology (from 3.7 percent to 1.8 
pemwt) . tionen's interest in the category tenned "^therapist** has 
reeoained relatively staible over the period; nen have eodiibited gradually 
Inonaasing interest over the years (Oxperative instituticnal Itojimrh 
Rnogram, 1987). 

Aoademic administratorB are also oonoame d that with fewer s^plicants 
ftae which to select^ the quality of stutkncs will declim. !Qais far, 
except for the areas vt clinical laboratory eoienoes and radiogreqptiy, no 
iecraaee in student quality eeens to be evident to program directors, as 
tteasured by the CHOBK survsy. More objective evidence for assMsing 
quality changes, such as grade point averages or test scores duriiq 
students' first year of professional ooursewo rk, is not collected. The 
Anarioan OcAlege Testing Pkogrem (ACT) test sooru of hig^ school juni (cb 
intending to major in allied haalth fields do not bsv out a shift ir 
quality (see IMble 5.1), Blttax^ the downward trend in dental hygiene may 
deyerve scne at'^ention. 


TMOE 5.1: ACT Test Soosre Means for Students S^pecifying Acadonic Majors 


Acadaodc Major 

ACT aoqposite Teet Scores 






Dented Assisting 





















niycdcal Thetapy 












MUnincr (R.NO 












Overall college- 
Bound Population 




18. V 


SOUROE: American Oollege Testing Program, urpdoliAed data. 

Not every allied health field has cdqperiflnoed an applicant deficit, 
as evidenoed by the oqperienoe of {iiysical therapy. Despite a xiq;>id 
incxease in the estiiblifii'^ent of physioa. theregpy prograoB, sost 
directors report that they still have sore than an adequate nvply of 
applicants and can liaiit «rirollJBent to thoam vith hi^ grade p /int 
averages. It is not unusual to find physical tiwrapy prograins vith 
applicaticn to aooaptanoe ratios of 10 to 1. Ih addition to p^ical 
therapy, a tm of tha nawer profaesions such as perfUsioi and diagnostic 
wdical sonography are also in great demand with about €0 percent of 
pccgram directors mpsrimdug application incxeeaee (CMIE^, 1987) . 


- 4 - 

Because they axe fewer in nunber and smaller in size it is difficult 
to egoate tte suooess of prograns like perfusion, for tooBplB, vlth 
geogaoBB in ihysical tterapy. Honethelass, it is vcactti noting scne of the 
diaracteristicB of perfusion prognoB. Students are (tften drawn frcn 
cthtr disciplines (zespiratocy therapy and critical care mrsing, for 
ey^le) and therefore have had scne eD y os u pe to the new field. 
Baploynait qppartunitiss ateund and not all graduating students enter the 
clinical field, since other attractive opporbmities are often available. 
9or esonple, ■anufacturen and bionedical engineering laboratories hire 
sens perftisionists; sobm enter aadical schodl, and others dvxse 
teaching. Altlxug^ perftzsion is a hit ^fUess poifeesian, it is also a 
relatively well paid cne. Ihe average salary fdt a graduating student is 
$35,000, but hi^y qiwiUfled and ao^ierienoed perftb^ionists any earn close 
to $100,000. liiile not Xnown to tiie general p W iir, ferfUsicnlsts are 
respected in the allied health %iorld for their success ir garnering 
earnings and their relative independanoe (Brown, 1987) . 

fVqr do ecne pnqjiaws f^ better than others in attractir^; students? 
Som reasons come readily to adnd. Uhdoubtedly the positive economic 
outlook for physical therapy— rising salaries, growing autonony, and high 
denand for graduatas— has affected student thinking. Also, in oonparison 
with fields such as Clinical laboratory technology, pt:ysical therimy has 
greater pti al i c visibility and nore patient contact. 

Siere nay be lessens to be learned frcn schools of social work which 
have had miooess in increasing their api^licant pool txxn 2 i^licants per 
opening in 19r3 vc 3.5 applicants per opening today. Social wotx is 
consider to ne closely related to (if not directly under the lafarella 
of) allied health. Deans of schools of social work erttribute the 
revitalization of interest: in social woric careers to a wide variety of 
social und econcnic factors, including: 

o cptiaian about the status of social welfare progr ams in the 
post-fieagan era 

o a wrge in the sense of social oomoitaant among students 
(but not an dranatic as during the 1960s) 

o occupational outlook prpjectionB of hi^ier than average 
growth in dnend 

o the grcwfh of ijxSependent practice and tMrd-pe .y payment 

o scBie schools adcpting 'Ojusinesfi-like*' anproeches to 
aarketing and zeciuiting students 

o salaries, while not hi^ initially, that averaged about 
$27,8'K) in 1986-87 (i^aalth ftofessiom Report, 1988) . 



visibility and ocn{)iu»tively hi^ pay axe elenents that contribute to 
the attxactiveness of a field, and in turn to achobls' suooees in 
cbtaining hic^ aiplicaticn xates. Sane fields that are viewed by the 
allied health comunity as being attxactive and of f erijig well-^ying 
careers nonstheleas do poorly in attracting students because they lack 
visib ility. Itar exBOfim, oocqpoticnal therapy ihaxes aguny of the 
attri]butes of (ivBiGal therapy, but its role in haalth care is not well 
kncMn. Madioal record aikdnistratarB can eaxn over $50,000 per year and 
advanoe to hospital Mcecutlve positlonB, but that field, too, is little 
known to the; piAic. 

Sam allied health ooofjations, such a", awtiral tachnolog/ and 
radiograiiiy, do not offer particularly good eoonondc xewaxds but seek to 
attract scimtlf ically orlentad students to vcxk. in potentially hazaxdous 
anvixonents «here they wev be eaqpoeed to oontaminated bod/ fluids or 
rad iat i on . Nooceover, although labocatory and radiography cnplcyr-nt 
prospects aay be rebounding after WS cutbacks, the atnoeitexe of job 
insecurity aay still be influencing students' peroqpticm. 

Student Racxuitnent 

Mtany of tlie social factors ttett influence career choice are beyond 
13)9 control of health care institutions or acadeodcs. Ihe eoancnic 
attractiveness o£ careers and work environnent is largely in the hands of 
enployers (a topic we will address in the next che^Jter) and those «to sake 
ni ntxu'MiiM iL decisions. 

Itaere are a naber of techniques that schools have used to attract 
students, taong thea axe the use of professional xecxuiters, giving 
faculty release tine to visit hi^ sdirol counselors and students, 
distribution of videotapes, and undertaking national pxanLticns (such as 
Lab Naek, fostered by the Anerican Society for Medical Technology) . 
Ikifortunately, efforts to inflvanoe career choice toward an allied health 
field have not been ^Btaaatically docunented or evaluated. 

Many psychological and social theories of career choice and career 
developnent have e m e r ged over the years to aaqplain hov individual caxeer 
develcpeant unfolds across the life span. Ihese theories suggest the 
difficul t ies of intervening in a oaq;>lex process, career developient is 
shaped by an interiaay of psychological attributes, knowledge About 
training xaqpriraMnts, educational and occupational opportunities, genetic 
and childhood influences, evolving personalities, and patterra of traits 
that individuals eoqprsss cognltively and psychcOoglcally in their choice 

behavior, nee It related to career developaent finds that, like all 

honan behavior, it is a hl^y ooopleK process and is part of tiw total 
fabric of perscradlt^' (Isnt, 1986) . 


Mast of the existing qpproadies to caraer developnent are based on 
limited sauplas of lelntively privileged petnons. Ihe sanples taJcen have 
typLcallY been mnjuaea oC nan xather than of wonen, and the aijproaciies to 
OBxmt develcpKnt have, in general, been addressed to pezBcns in the 
■idJl*» range of aocioeoeraiiic diaractaristice. Ooraequently, these 
aifaroaches tend to cafhasize the oontizuoue an* progressive aipects of 
career devvlopnent that are possible prlanrily for perecns %to are 
relatively free to ctxxse any career, and for whom both p^chological and 
•ocranic reaouroes are available. Such criteria do not neoessarily fit 
mnen and ainorities (Crites and Fitzgerald, 1980) . 

Ihe iapact of aeveral variables (including parental socio-eooncoic 
status (SES) , jjnartmln achievwent, and sex) on both, selection and 
persistence In career choice has been investigated in an attcnpt to 
detemine \iho is being recruited into pr^essions in general. Ohase 
-variables i«re used to analyze reeponses fron the Depertaent of 
Bduoatian's 1972 Rational Longitudinal Stul^ (NI5) end recent follow^ 
surveys. Results ihawed t^2lt children of high SES parents are four tines 
■ore likely than children of low SES parents to engage in professional 
study at the baoQBlaureate level and six tiaies noce li)oely to participate 
in cr ocnplete professional training at the graduate level, ihe SES level 
of parents does not have as nxh effect on the aspiratiom of children, 
taoMBverf children of hi^ SES families are only twice as likely to wish 
Cor a professional career as their contenporaries from low SES families. 
BBsearchecs conclude that the idea of substantial social and econGnic 
■obility in the Ofiite^* states has been exaggerated and is difficult to 
achieve. Gnly two puroent of young people from low SES homes were in 
graduate-lcfvel professional piogiaiub seven years ^fter high school, 
daqpite large federal student aid prog ra m s and nomerous oozporate and 
fojndation ptugiamB to stimulate opportunities in the professions (Miller, 

m general the career choice literature does not provide detailed 
9aidanoe for recxxaitnent efforts. But some implications for specific 
pJanr ^ng interventions can be drawn. 

o Ihe concept that people rre only econcaiic an Oa and that 
MDiric is chosei only for the livielihood it ofiers is too 
simplistic. Mock also provides a means for meeting needs of 
social interaction, dicpiity, self-esteem, 
self-identification, and other foms of psychological 

o Baraonal, aduoatiena} , occupational, or career matuti^stion is 
umprised of oonpleK learning processes that begin in early 
childhood and continue throuihaut life. 

o Choice oc cu rs not at a point in time but in xexation to 
anteoedent eoqperiencas and ftiture alternatives. 

o Chreer InfannatiGn mst include not cnly objective factors 
Mch as earning possibilities, training regLiirenaits, and 
nnbers of positicsis available but also the social and 
psyctaologioal aqpects of careerB as veil. 

o Oaxeer choice Is frequently a amn'Mnisfr between the 
attxactivaness of an alternative, the likelihood of 
attaining it, and the costs of attaining it (Herr and 
CroBier, 1984) • 

Ih siannary, tiie litnatura cn career dnice is suggestive rather than 
prescriptive fbr xecxuitnent tactics. Long^-rmge efforts oust take into 
account the need to sake individuals auore of careers at an early stag^. 
If woman continue to predcninate in aany of the allied health fields, ve 
wst learn man about the (jtynamics of their oaraer choice behavior. 

SuooessfUl student recruitsnent efforts genenlly depend vpon positive 
narket signals enanating trm the vorld of %iQdc« In the next chapter the 
conndttee will disaws actions that anployers aust take to istxrove the 
circtnstanoes of allied health persomel in work rsttings %here the 
perceptions of unsatisfactory careers accurately reflect reality. 
However , to the extant that potential students inoorrectly believe that a 
career is unsatisfactory, the prcblan my nq^ln isproved conramicaticn. 
local consortia of professlGnal assodaticn nsiters, cnployer 
xeprestfitatlves, and educators should be fanned to devise recxuitment 
strategies besed cn comiunity ner Js, charac-* terlstics and resources. 
These ocnsortia ahould target nontraditicnal uidienoas^ tailoring the 
WBSsaqe and mOiod of ccnnunlcatlon to each* A narkstLig plan geared to 
attracting nswly-wenployed wncken trm a local industry, for exanple, 
rtKuld not be the sana as one that seeks to a t tr act diwplaced honsnakers 
or handicepped hi^ echool students* 

Denand for technically oriented people is groidng in many sectors of 
the econcny* One study predicts that; 

The jobs that will be created betwaen 1987 and 2000 
will be substantially different fkoD those in exisfenoe 
today* A nunber of jobs in ttiB least' 3killed jcb dBBBkJs 
will disappear, %hlle hi^^i-skilled professions %dll grew 
nqpidly* Overall the ddll mix of the eooncny will be 
moving rapidly qpscale, with most new jobs denmnding more 
eduoa\:ion and higher levels of language, math and reasoning 
aikills (Hudson Institute, 1987) * 

More iqpecif ically, over half of the nai^ jobs created between 1984 end 2000 
will need mam hl^ echool eduoation* Nearly a third will require a 
collega degree; today, only 22 percent of ocoupatloni zeqpiire a cbllega 
degree (Hudson institute, 1987) * Ttm health industry is not the only 

industry that is beglming to understand that one of the challenges of the 
future will be to poslticn thmelves favorably in the ocnpetition for the 
•fply of educated, technically able workerB. Ftxr ecne aUied health 
fields there are alraad/ indicaticns that potential pFBctitionerB are 
being lost to other fields. It is clear that educators, cnployers, and 
the professional aasociaticns wst act if they want to naintain or 
inczeese their Aare of the mtkforoe. The prooess of change ia 
neoessarily interactive. If «i|aoyers sucxaeed in xaaking allied health 
enploygnnt aoce attmctive, educational institutions %iill eagaerieaice 
increases in the size and quality of the applicant pool. But, circularly, 
the extent to %hich enployers are able to alter the oaidltiora of 

in part on the education that workers have received. 

in doae 

ilaticna. camaniM far 

seek perBcna 

a. career Aanaare. thaM 

epDlioant pqqIb— 

already aiploved In hwalth rm. mw; fin fields vtoe thev 
underreDreaenfpr1\ unrt <Trf1v<Ai«.l« wi»h h^T^Wiaina oondltlons 


IVro aajor societal problens underlie concern about minority 
participation in allied health careers, leading the ocmnittee to devote 
special attention to this issue. 

First, as several reoant public policy documents have stated, 
minority populations in the Ittiited States have oonparatively poor health 
status and use fewer resources relative to their needs. (U.S. Oepartstent 
of Health and ttanan Services, 1985) . Althouglh a causal relatiorahip 
betueen the simply of ninority practitioners and iapx^ minority health 
care and health status is difficult to validate, minority health care 
workers are more UyjBly to work in geogrE!:4iic areas and delivery sites 
that serve minority and other disadvantaged patients. Officials 
interviewed at three imer city hospitals, including two puialic hospitals, 
said that minorities are at least SO percent of their total allied health 
%Kjrkforce. Moreover, data octracted trm facility zecords ttau that this 
pattern is relatively imif am acxoss the different oocqpationa such as 
clinical laboratory, physical and occupational therapy, dietetics, and 
medical records (Booker, 1987). 

Second, there is a lack of parity throug^iout society beteen whites 
and non^uhites in professional positions, lb the extent tiial the allied 
health fields can provide iiprcKw! career opportunities for minorities, a 
double benefit will occur. Bdkc . ion pruyiaBS will be better dble to 
maintain «iroUments and persomea ihoa±ages miy be alleviated in 
underserved geographic areas anl Institutions that serve poor minority 
popula t ions. 


To nqpplanait a nviflw of 1^ litentuie on rqpfresentation of 
■inoritlM in allied health fields, the oamdttee oondbcted extensive 
interviews with deans and f&culty of ten schools active in the National 
Society fbr Allied Health— an organization ocnnitted to increasing the 
p arti c i p a t i on of black and other disadvantaged ainorities in allied health 
practioe, education, and adtadnistration. Other schools were aiUed in an 
attttii^t to broaden the iitfbmtion base. A school known to have a 
predoninantly Hispanic student bo^ and stiucturaL activities to recruit 
Hiqpaniss to allied health tittigiaiMs was selected; so was a school in an 
area %dth a large taerican Indian population. Finally, a non-ninority 
school in the south was added bscause it boesU the largest nxab&c of 
allied health ptuynum on a single caBpus and has bsen actively involved 
in ainority allied health recruitaent and retention efforts for some 
(Bookar, 1987). 

Tedsle 5.2 presents estJmtes of racial and ethnic characteristics of 
allied health peraomel based on the results of an anal^is of the 1980 
census. Ohs data liiow that ninoritj' persomel are uiderxcpiresented 
relative to their representation in the U.S. labor fbroe in the ten allied 
health fields the oonnittee studied, particularly the fields requiring 
higgler education. 

CMIEA reports that over the entire range of the fields it accredits 
ttie racial six of students enrolled during 1986-87 generally mirrared the 
racial aix of the U.S. population. Blads represented 11 percent of total 
enroUnent, H lepn ni cs 6 percent, and American Indians daout 2 percent. 
Itiat these data fail to reveal is that ninarities are overrqjresented in 
fields requiring less education, end underrepresented in fields requiring 
sore education. It is not kncwn the extent to vhich minorities have a 
higher departure rats ftcn iiiugiaius and careers. Several professional 
associations in fields requiring baccalaureate and advanced degrees have 
comnented on the need for a greater effort to incxaase the nunber of 
minority students. For eocaqple, the 1984 Study GonnisBion of the American 
Oietstios Association noted: 

ftiile no effort has been made in the past to restrict 
other racial groups, or males, frcn the profession, little 
has been done to make the profession more attractiva to 
then, nor has any strong effort been made to recruit them. 
Ihe 1984 Stud/ OrTwilesijn believes such an effort is 

Itet Efforts lb mczease Minority Participation 

TtW FMffinT Govgrnnent ihe federal govemimnt first initiated programs 
to enoourage "culturally or eooncnically disadvantaged individuals'* to 
enter allied health -m part of the 1970 health ranower legislation (P.L. 
91-519) . Ihis statute was extended in 1973 by the Oonprehtfeive Health 
Manpower Act (P.L. 92-157) and the Health I%ograas Bctansion Act (P.L. 

- 10 - 

TAiU %.2i Ofttrfbutfon of Nrtoml In Stltctad AlIM NtaltH ritldi bf Raet 

or Ithnfc Orf9fn« mO. 

cnov or ipviiiii 


Cl^fili Orftfn) 


Uboratory T^efmfcfm 





Otntal NysltnUtt 









IMical Mcord Tichnfefm 

i •4.4 




Oco^tlml Tharapisu 





Phytfcal Thtrapitts 





Mielo0ic Tadmicfm 





tMpiratory Th«fipisU 





tpMdi and Nr^rfng Thtrapfsta 92.9 




nURCE: HMlth Rmoutcm wid S«vic« Adilnittration. An ln*D«pth Euainitian of tiM 
1960 Owwnial Cmui, tapto)wnt Data for HMlth Oeci^tloni, U.S. 
O^MrtMnt .f Naalth and Nuan Sarvicat, 1964. 

* Includaa taarlcan Indians. Japanaa a , and othtr «a1ant or Pacific Istandara. 

93-45) and in 1976 by tte Health ftofessiora Eduoationai Assistanoe Act 
(P.L. 94-484) . An administntive decision vau side to provide wjppcaX for 
projects that aqphasized the fttcxultnent and xetentlon of ninoorities and 
the disadvantaged (Chxpaiter, 1982) . 

BetMeen fiscal yeaxs 1972 and 1977, approodnataly $20 Billion of a 
total of nearly $191 aillion of grants aMardM for allied health %«s 
allocated for ptt qr a a e targeting ninority anV'or disadvantaged 
populations. Ih the period between 1978 and 1981» under P.L. 94-484, a 



larger itaie of tte total, taut analler aocunt, was awarded for project 
activities to assist disadvantaged allied health students (Carpenter, 

Ey fiscal year 1982, the only federal funding available of ary 
aagnitude for uinarlty reczuitnent and retention in allied health training 
%ns the Health careers qppoctunity AnogiR*^ (HOOP) . HCDP has five 
objectives: recndtanent, prelinlnary r aition (nan-credit) , facilitaticn 
of entry, rstmtion, and infocceticn disueninaticn. Bcanples of 
activities inclvde career fairs; faculty counseling; tutoring; sunner 
mrichnent programB to crtianoe Batiwnatics, science and ccnnunicaticn 
skills; and linkage arrangenents anang undergraduate schools such as 
Historically Black Oolleges and Iftiiv^rsities (HBOIs) , ocanunity colleges, 
and hi^ schools. 

BsbMaen fiscal years 1982 and 1987, the nsber of allied health 
grants under HOOP increased steadily, as did funds awarded. Of the $60 
nillicn or aiore awarded since fiscal year 1985, $5.37 million has gone to 
allied health pcograins. Ihe proporticn awarded each year to allied health 
p f ujia a s rose traa^ 5 percent to nearly lO percent during this three^ear 
period (Holland, 1987). 

The Area Health Education Oenters fvogam (AHEC) assists health 
professions schools in isixroving the distribution, supply, quality, 
utilization, and efficiency of health personnel in the health service 
delivery syston by encouraging the regionalization of professional 
edication. AKBC has no legislative mandate to recruit and ret&in 
minorities, but it has coqplicitly enoouraged such activities. In fiscal 
year 1987, AHEtSe in Arizona, New Nexico, T&tas, California, (Mahona and 
at three black medical schools-^lraf (Los Angeles) , Hdiarry (Nashville) , 
and MoTBhouse (Atlanta)— were cited fay the AHEC officials as having active 
oonnitaents to training professionals to serve Hispanic, Indian, and blade 
populations. Ihe AHEC financial inves t ment in recruitment and retention 
rt minority allied health students and workers is not oistainable trcn 
available pro g ra m data (AHEC, 1987) . 

Sta^ Most state's health professions education p ro gram atic resources 
have been devoted to ijicressing the sipply minority pnysicians and 
dmtists, faut a few states sipport initiatives for minorities in allied 
health training. Fbr eocanple, Connecticut funds a Health Sciences Cluster 
ftogram vhich eoqposes high school students to allied health professions; 
ecQncnically disadvantaged students in allied health in Georgia are 
eligible for a snail grant program, the Regents Oiportunity Grant Krogram 
(Itondex, 1987) . nie State of New York has developed an action plan to 
iaisove minority aooess to the licensed professions (including dental 
hygiene, epeech-language pathology and audidogy, piiysical thengpy, and 
ooopational thenpy) , the core of which is a ooqprehensive effort to 
iifnxive curriculiB developnent and teaching in mathenatics and science in 

- 12 - 

grades 7 throucfh 12. m adUiticn, th* stats offsrs financial assistance 
to allied haalth students willing to %iork in state agencies after 
graduation (Nev York Stats Bduoation Dqpurtaent, 1985) . 

Allied health is larsly qpecif Ically iteitif ied in stnte legislation 
for targeted funding. Several investi-^tora rvport being unable to 
ascertain the anamt apertt for allied alth education because they axe 
not distingpiiidied fron qppraprietiGns for 'tedioal ed'Kation'*. Of 13 
allied health pcogram officials interviewed, only one reported ttiat their 
program reoeived finds for minority recxuitaent and retention through a 
line itn in the state bulget. 

Private PtaundatleM M.vate ocganizatiora also see merit in 
encouraging minorities to select health care careers. Ohe Josiah Macy 
Jr. , and ths Robert Mood Johnscn f cundatiors have bsen very active in 
these effdrts. HcMever, Robert Mood Johnson Foundation's staff report 
that ooxsnt activities do not iTidude allied health professiom. Macy 
has qponsored sons allied health pr^essions training, but its priaary 
focus, after more than 20 years' involvement in minority health 
professions education, is still physicians. The Macy eoqperioice is worth 
describing in some detail because its potential applicability to allied 
health education. (Olie following description is taken from Bleich, 1986, 
and Bleich, 1987.) 

Ihe basic concept of Macy's High School model is to use foutxlation 
funds to supplement taoe levy sifport for participating schools. 
St r engthening curriculun and pr»iedical advising early in a hic^ school 
stuSent's e du ca t i o n are the centerpieces of this progran. Linkages 
betoiiea) colleges/universities and the hic^ schools are " ■■■ " ■ t and serve as 
vehicles for faculty develotnent, student esqposure to careers, and 
academic enhancement. 

For exanple, five hi^ schools located in the three poorest counties 
in rural Alabama (50 percent of all families live below the federal 
poverty level) have ocnpleted a four-year cycle in the Ma<y Project. Macy 
reported the following results: 

79 percent of the originally selected 114 students were 
retained in the honors pr og ram 

100 percent of the honors students scheduled to graduate did 
so and are going to college; all but two anticipate 
attending a 4-yBar school 

33 of the 88 graduates specified that they would pursue a 
health career; three cited physical tbsapy 

Macy graduates all took the mathematics placement exam given 
to all Uriversity of Alabama inocmi g freshmen; 88 percent 
plcioed into ca?.culus or pre-odculus: 55 percent in 
calculus, 33 piiroent in pre-calculus. Macy notes that less 
than 10 percent of all Alabama freshmen do as well (Bleich, 
1986) . 



Ihe program in these sciwols, called BicneAical Sdenaes Freparatlcn 
PkogrBD (BloI>Mi>) and cperating in grades 9 thiouc^h 12, is ocnducted in 
ocnjunc±ion vith the Univexoity of Alabadna School of oomunlty and Allied 
Health, a school ocnnitted to increrising the nmber of health profess- 
ionals pcacticing in xural Alabama. Muiy of the Macy graduates (57 of 88) 
weia ouBxdad tuiticn sdwlarBh^ by the Univers' ty. 

Vriar to BioKip, actool systeoB in the thi«N< ccunties (two of them 
predcninanay blade vith a nadian of 8.5 ocBi>letad school years) vers 
unablm to jjdentify i^iftad and talented" youth. Kacy schools \mte able to 
attract na» than 100 young people to its "rigorous acadendc program which 
has flEiii^asizad acicnoe, mathematics and language ddlls." Initial 
ooiK a m B about schools' dsili^ to attract sufficient naters of students 
for the piugiam have prcwed to be unfounded; nev Classes are being 
enrolled in several schools and "in each setting there is growing interest 
and daiand for a more rigorous curriculun" (Bleich, 1986; Eleich, 1987) . 

Bcteraive in-service training has taken place; curriculun develqpnent 
has been a odlaborative activity between the high school teachers, 
BioFkvp staff, and selected Uhiversity faculty. T\itorials, enhanced 
scienoe laborataries, and independent study have been offered at the 
schools; bi-nonthly Saturday sessions and siaMtfeek sunoer ptujiaiub have 
been held at the lAiiversity of Alabama. 

Mbcy reports that more than 1,200 students have enrolled in their 
projects. Ihe founaation projects that more than 4,500 students will be 
enrolled in grades 9-12 when programs are fully established, and schools 
will graduate 700 college prepared minority students each year. 

Other high schools in the p roject report results similar to the 
Alabana e)qperience, lending credence to the potential of a model that 
blends public and private resources to effect systenic changes that can be 
iiBtitutionaliied for long-lasting benefit. 

Lessons That Have Been Laamed 

Hrre than 20 years of experience in attenpting to increase the nunber of 
minority allied health professionals suggest four areas that shculd be 
targeted for action: 

o acadendc preparation, especially in the sciences and 

o Icnowledk^ of allied health careers and ptonotion of 

o financing of instituticns and students 

o lihkages and affiliations in training and cnployment. 


14 - 

Despite efforts of the fecferad govemoent and individual 
institutions, barriers to allied health oareers for minorities that vere 
cited in the early 19708 renain serious pirQblans. Can lesscm gleaned 
fkon past efforts L"ifom policy nakers and eduoators about lAiat kinds of 
invesbnants need to be made in the future, itere they will be most 
productive and %hich stakeholders can lead aid oontribute to greater 

Academic PttWTitlgT Astin (1985) notes that ninority 
underrepresentaticn in mginsering, biblogical sciences, the physical 
scienoes, and natheniaticB can be linked to lew levels of academic 
pmaraticn in aathfiBatics and scienoe prior to college enrollDent. 
Acajfemic preparation is also the ointeal issue that affects the size ard 
quality of the ninority applicant pool for allied health training. Allied 
health deans and program diracturs fixnly believe that streams of 
qualified ainority applicants cannot be relied i^pon until academic 
deficiencies are substantially reduoed (interviews, 1987; Hie Cirwle Inc. , 
1987) . HOOP grantees have ^ically focused on strengthening the skills 
of disadvantaged students in ocnnunicatiora, mathematics, and the 
scienoes. Six- to eic(ht-iiieetk sumner enric^mient and tutorial prg r v^ m K are 
the usual interventions. Ihough there is partial evidence (La Jolla, 
1984) that such interventions can vork, the conventional wisdom is that 
the cnphasis on mathematics and scienoe should begin as early as possible, 
starting at or even before junior hlc^ school (Bisoonti, 1980; Mingle, 
1987; Flack, 1982? Ttm Circle, Inc., 1987, National Oarmission of Allied 
Health Education, 1980; La Jolla, 1984) . Perhs^ allied health schcx>ls 
could gain more by helping to create alliances with others in the 
comunity to attacic root causes of poor academic preparedness. 

Allied health schools generally draw their students ttm )cnown feeder 
sources. Strengthening academic preparation at the secondary school level 
and in other major feeder echods (e.g. , ccnnunity colleges) can 
oontribute to lasting iapro v ements in the quality of their i^icant 
pods, influence curricular iaprovane n t at feeder schools, and faring 
greater visibility to allied health career opportunities. At the same 
time, early academic and career counseling, a conpounding factor 
(mtervioMs, 1987; The Circle Inc., 1986; la Jdla, 1984), can be 

Ihe Josiikh Macy Jt. Foundation provides an exodlent exanple of what 
can be acooBplished if students are introduced to intense f^f^ii^^in skills 
iata-o v cmait inugiami early. Itacy's success also provides an exanple of 
what can be aocaiplished lay approaching problens from a broad 
perspective. Ohe foundation inoocporated a %dde variety of resources and 
addressed areas other than the student's grade point average. Ihey also 
concentrated on raising school administrrtors' and teachers' eo^ectaticns 
of students, educating parents, acting as liaison for establishing 
oollaboraticns between colleges and ptdblic secondary schools, and raising 
students' sdf esteen. 


- 15 - 

BWWlfli ro ^ ft^^cmrt ion Pf J Mlled Health Rrpfcsslcns Inf omnation pli^ a 
Tdm both in attracting ainority students to oazBers and in kaqping than 
throug(h training* infooaning ainarltiss about the %dde nuige of allied 
health oooicationB and ptoBoting these as oareer cpticns is an isfxxrtant 
step in attracting thai to these professiGns. 

Bducatocs believe that better inf onnatlGn about the nature of the 
training and practice is a crucial factor in addressing the relatively 
hi^ attrition of Binoority students in the first year of professional 
training. But infdnpation is not aasily cone by. Allied health 
professions are not videly wntioned in the redia, nor are the 
oontributions of allied health oocqpstions to health care delivery 
esq^aained (SO^iiaaa^Sm, 1987). 

Ihose interviewed report that inf onation ill semination througlh 
career days, distribution of bcoctaurBs, and active recxuitnent is most 
effective %hen ooqpled with formal and informal linkages with feeder hi^ 
schools and colleges. Ont school %hich recently began recruiting through 
ch ur ^^ reports this as a rich and largely untapped source of minority 
allied health applicants. 

ntfiiuemii data and experiences of recxuitere suggest that the 
foUowing factors ihould be taken into account in ahzqping effective 
infocDation di semi nation and prcnoting canpaigns; The Circle, Inc., 1987; 
Hingle, 1987): 

o Minority allied health students are more likely to be older 
and to have children than are liberal arts students. 

o students demons t rating potential in hi^ school or ocmunity 
colleges nay yield more growth in the applicant pool than if 
recniiters focus priioarily on hic|h achievera vho are also 
heavily advised and recruited fdr aedicine, engineering and 
other professions. 

o OcBBunity colleges can becGoe a good scuroe frcn Which to 
drav students interested in earning a bachelor degree, 
especially if liidcage arrangenents that i n co r po ra te 
approaches to diarpening critical skills and increasing 
students' awareness of career options are hiplenented. 

o Persons dJaendianted %dth their current occtpations in other 
fields nay be seddng an cfportunity to pursue a challenging 
and rewarding career (The Circle, Inc. , 1987) . 


Hnancinn of institaibifapo flnfl fftirMTTf Def iciflnci«s in acadendc 
prepaFatlcn are fairly vidaqpiraad amcng oinoarity allied health students, 
and deans of allied health schools expect this tertooning to continue in 
the near tern, ihoy believe that financial ci^port will oontime to be 
needed for activities that he]p struggling students zonain in school. 
Ihese activities include pie i i aUi culation mauer prograns, facult/ and 
peer tutoring and camelling, cca|»ter-eidBd loazning assistanoe or 
instzuction, and currioulvn i inii 'C M Bi wn ^faculty develcpment with feeder 

Deans of allied health schools concluded that axtetnal stvport such 
as HCSP is essential to underwrite ecne of theee institutional co^ienses 
CDie Circle, 1987) . In gmral, intensive alnority recxuilacnt ani 
retention activities arc st^ported, at least in part aid ftecpently at a 
substantial level, by external finds, im^ has been predoninant here (for 
all activ ities except curriculum iaprovonents in allied health training 
prograns) . A 1984 asonnnBipiit of preparatory activities sqpported by HOOT> 
(i.e. , preliadnary education, entry facilitation, and retention) oonclucled 

Since by far the largest e>9)enditures for HOOP are for 
preparatory activities, it is essential that HRSA [Health 
Resources and Services AcMnistration] and the grantees 
focus apft n ial attention on providing those preparatory 
activity services that produce the greatest benefit to the 
objectives of the I1CX»> program (la Jolla, 1984) . 

Since 1978, finding fbr allied health under HOOP has increased as a 
proportion of the total HCQP investment, but total funds tctc the p roq z e u tt 
as a whole have fallen and authorized purposes have been nacre narrowly 
defined. Far exanple, there are currently no federal programs that 
«ppMt developnent of minority allied health faculty or curriculum 
iaprovenents in minority schools or in non-minority schools that me& 
omrioilun changes as one vsy to recruit and retain more minorities. 

Programs Mch as the Minority Access to Research careers (MNRC) and 
nijnacity Biomedical Uneniiuh Support (MERS) , tt» oldest and preeminent 
among existing minority-ariented p rog xai a s administered by ^ Itational 
Institutes of Health (NIH) , sqpport these Idnds of activities. Ihese 
programs have been credited with contributing substantiaUy to increasing 
research, r es oarch training, and the nunter of reeearciierB in iistitutions 
that train large nmbexs of minorities. Ihduded in this cluster are 
significant nmobers of traditionally and predominantly minority schools 
(Garrison and Brown, 1985; Gonzales, 1987). 

Along with institutional mjppcact, insufficient student financial aid 
is seen as a de te iTen t both to minority sbdent recxuitamnt and 
retention. Deans cited money as a major reason for student attrition. 
Mary minority allied health students are older and have children, l&xiy of 

- 17 - 

these studoits find that schedules ^enenlly do net permit t^lan to 
oontixue %Kxrking. In such cizcunstancaes f ineuncial aid is a cxucial factor 
in their penistenae touazd a degree. Bisocnti (1981) notes that **a 
degree in an allied health aajor fteqpiently is noce expensive than a 
libei.'al arts degree. Hdticn oosts my not be hi^^, but there may be 
add-cn oosts for dinioal eduoaticn, materials or ec]ai(nant, and the 
period of training (both pre-professional and profeesicanal) mey be longer. 
Although states are investing in the education einport of minc^ity health 
professionals, the size of these investments varies widely and most state 
aid is targeted to medicine and dentistry. Ihe ocBmittees' interview 
reqpcndents feel that states need to provide anre student financial aid. 
Models that have suooessfolly ocntributed to shifting the distribution of 
nedical and dental professionals (e.g. , Ifational Health Service Oorps, 
jioan forgivmss, AHEC) , tay offering incentives for minority professionals 
to %iark in mdereerved areas are strategies that may be applied 
effectively to allied health practitioners. 

Idricaoea and Af f iliatigans in Trainincr and Enplovment Linkages amcng 
colleges and hlg(h schools are placing an increasingly iscxsrtant role in 
encouraging the training of minority allied health professionals. 
OirectorB of allied health ptuyiam with and without HOOP grants 
adcnowledge ttmix value in recruiting students. linkages with high 
schools for recruitment purpoees appear to be ^^ecooing more formalized, 
perhaps in lesponse to the continued eqphasis on linkages to hi^ schools 
by HOOP since 1981. Data show inore linkages exist with hi^ schools axKl 
to four-year historically black colleges and universities than with 
oonunity colleges. However, some schools that todq^ lack ooniunity 
college linkages report plans to explore these arxanganmts. linkages 
appear to work well %Aien there is shared ocmnitment and nutual benefit 
regardless of whether the arrangement is formal (as in a written agreement 
that speci f i e s responsibilities and benefits) or informal (a working 

Ihe predcninatly minority achools we contacted report no difficulty 
in finding adequate clinical placements for their students. Ihe^e 
placenentb are most often in areas with large minority populations. 
Programs are today very dependent on hospitals and have limited wperieanoe 
with other kinds of sites for students' clinical training, thus diracal 
training may be threatened if hospital revenues axe reduced. However, 
several schools reported that clinical sites pay the tuition for students 
they accept for clinical placemesits, usually because the ho^ital is 
interested in hiring students \t)o train with them. This interest should 
help sustain affiliation agreements between schools and hoqpitals, 
ecs^ecially if workers are scarce. 

No strategy for significant incxeases in minority participation in 
allied health professions will be successful unless it targets resouroes 
at the major barriers to minority participation, and involves the oonplete 



- 18 - 

qpoctnan of intuiMted parties, bGth in gcvemoent and the private 
eector. Minority ppg^itment offmtfl mifft bwin tefgre hlsh actioali— 

^Tfrifm^^ ^netitaitione mnyf ft^^^ gupport aervioes for i?etcntic3n and seek 
to fgcpcte tflafffitlfflTfl? *^nitY TP grrfffll .in thft ICT" tem these 

institutions , 

Ul^Jaately, suooass vill depend upon eOication institutions making a 
lGng"''tsnn ocBmitsitfit to intaoratinj ninority xtacxuitment and retention 
into the fidbric of their allied health prograns. Erosion of federal 
support for this objective vould undendne those in the education 
CGDBunity ite are struggling to gain or maintain such a nmwltnent to 
minority allied health edbcation. The onmittee endarses the objectives 
of the Health ftrPOT Qaportunitv Program ant^ t^UffVfff that funding levels 
llfffti fit ^ liit^n^ff^nirf nl^ Qirrent levels. 

Medntaining and Eb9)andi7ig Education Ce4>acity 

Itie future supply of nev graduates depends net only on students 
careers in allied health, but also on the maintenance and eoqpansion of 
education opportunities. 

Hospital qponsorad allied health education pr og ra m s suffered more 
closures than other types of programs. Ihree hundred fifteen ho^ital 
sponsored prxjgrams closed between 1982 and 1986, oonpared %dth a small 
nnber of proprietary scf^ool closures. contrast, a net increase in 
programs %ibs e}qperienoed by ocnnunity colleges (100 or 9.6 p er cen t ) and 
junior colleges; (26 or 4 percent) (CAHEA, 1987c). iBtie 5.3 shows the 
net change in some camEA^eocrsdited allied health programs between 1982 
and 1986. Much of the dadine in allied health education capacity can be 
attributed to the closing of hospital-based training programs—principally 
laboratory and radiologic technology. Rnograms with the largest nunber of 
vithdrawals frcn CAHEA accreditation (and pnesumad by GAHEA to have 
closed) are medical technology (116) , radiography (103) and respiratory 
therapy technology at the certificate level (29) (CAHE^, 1987b) . 

ADcng progr a ms not accredited by CKKEA, physical thercqpy grew 
rapid].y~f!rcm 84 baccalaureate pro gra m s in acMknic year 1980-^1 to 97 in 
1985-86, and from 9 master degree programs to 14 during that same period 
(Am, 1987). 

Iliere is no dear evidence that capacity in hi^lher education 
institutions is in serious jeopard^. However, pr o gram closings ooupled 
vith fears of a decline in the nmber of applicants have heiglhtenBd allied 
health piugiam directors' feeling of vulnerability, ihis feeling of 
vulnerability, mxpvoBseA by educators to the ocnmLttee during its 
deliberations, is due to the ocnoem that: 


19 - 

UffilE 5.3: Changes in the HaabBsr of CAHEA AoczBdlted Vrogpcms 
BetaiiMn 1982 an) 1986 

NUDDber of 

CMIEIk-Aocvaditad R togians 

in 1982 

NiBDlser of 
fto g ra iBS 
in 1986 



Medical laboratory Itehnician 
Medical Technologist 

Respiratory Therapy Technician 
MUdear Medicine Technologist 
Medical Rerxcd Administratcr 

Medical Re«£d Technician 
Ooci:()ational Therapist 
Medical lab Technician (Associate Degree) 
Reqpiratocy Therapist 
































Health BdunAticn Directory, 15th Bditicn. Chicago: American 
Medical AssocJation, 1987. 

o allied health education will not be able to loeLuitain its foothold 
in h universities 

o dincial education sites will grov scarce 

o financially stressed education institutions of all types, viewing 
allied health as a costly endeavor, %dll dose allied health 



Given the nation's projected need for allied health personnel and 
their relatively short stay in the allied health workfaroe (see Chapter 
4) , serious erasion of the eduoation ssctor's capacity to siqpply the 
nation «dth allied h^dth pexsomel aust be avoided. Ihe qjeeticn for 
public policy action is whether vulnerability poees a veal and present 
dangfer that cannot be wideessed by naiioet focoes alone. If govexnnent 
intervention anVcr private effects are recriired, «hat actions will offer 
the greatest zetum on public and private investaents? 'To answer this 
question, we oust first wderstand the role of various iiqportant 
decision-makers and hew their actions can strengthen or weaken allied 
health eduoation prog rans . 

Mio Influenoes Educational Qqpacity Decisiom? 

Ohe decisicn to open or close allied health pixjgian i L' or to expsni or 
contract entollnents is ostensibly in the hands of education instituticns 
theoeelves. Typically, a dialogue occurs bsb^s^. a dean or departsent 
head and the chief actadnistrator for academic affairs about the 
desirability of adding pr o grans or the need to close or reduce a program. 
Ihe resaarks of a university president, «ho earlier in his career was 
responsible for namouer projections at one of the allied health 
professions ass o ciat ions, provide seme interesting insights into the 
context of this dialogue: 

It obviously beoones floetrenely difficult for a 
university president to justify the continuation of this or 
any other program «hen student denand has moved elsewhere, 
say to real estate, and when the dean cf the school of 
business is clamoring for those scarce resources to be 
diverted to their firent. Further, since the average age of 
ay faculty is only 49, na^lral attrition does not 
facilitate resouroe ^litts. 

It inuld be easier for me to justify maintenance of 
hic^ cost prograns if external siroport %«ere still flowing 
to my canfMs, hoM^Aer, as you are" well aware, there has 
been a steady decline in the amount of federal dollars 
available for health education. Oherefore, academic 
administrators are on the horns aC a dilenna and now, liJoe 
health care iwtidnistrators, we most monitor the environnent 
oontiniously and respond to changes as never before. 
Strategic planning is the name of the game, universities 
can no 3 ^iger afford to be all things to all people 
(Perrin, 1987). 


- 21 

Decision Baking does not take piaoe in isolation. Mary parties can 
be invDlwd in prec^tating the dialogue and influencing the oouxse of 
decision aaking. This includes federal agencies such as the Bureau ol 
Health Itofessim (EHE^), state hi^^er education and lioming agencies, 
stats politioal leaders, aoctediting bodies, pcofeesional associatiora, 
and local health core providere. At tines ths pressures exerted by these 
parties, and oonvorBely the Offxjrtunitiss they have offered schools 
tiirough grant-giving, for eoonple, so oventela institutional outoncn/ 
t2wt it is difficult to disoem where ccntrol lies. 

Urn issue of oocitxol is an iaportant one because by understanding the 
distribution of authority over allied health education one can identifv 
hw the forces that ehape decisions About education oepacity can be 
influenced to accoqpliih public policy goals. Ihese goals vwonpass not 
only the size of enroUinents, but the quality of education, its content, 
and the ability of the sducatlon syston to add to the wockforoe. 

The Peder&l Role A ujor direct influence on the developnent of aUied 
health marpower training capacity has been the federal Bureau of Health 
^fessions and its p red e c ^ teso r organizations. 

In 1966, nrt long after Oongrees enacted federal education funding 
for aodicine, ostsopathyr dentistry, veterinary nedicine, optODetxy, 
podiatry, and phamacy in one law, and nursing under another authority, it 
also provided education funding for 13 allied health fields. Ihe Allied 
Health Professions Bssonnel Ikaining Act aCfemd five types of grants: 

o oonstruction grants for training oer/';ets and affiliated 

o basic iiqprovanent grants awarded on a fomula of $5,000 
tines the nunber of eligible curricula in the oaiter plus 
$500 '-JmB the nunber of full-time students receiving 

o grants to tuppart tzaineeshJ^js for allied health personnel 
to beccne teacheni, ad m ini s trators, snqpervisors or to serve 
in aUied he&l/ch specialitiw 

o •*new nethods" grants to allied health training centers for 
projects to develop, dnonstrate, or evaluate curricula for 
the training of new types of health technologists (U.S. 
Department of Health, Education, and Welfare, 1987) . 

Table 5.4 depicts the funding history ot this law and its s ^yxfiWQr 
pieces at legisla t i on . Although no federal pr o grans have qpecifically 
sifported all^ health training sinoe 1981, allied health students and 
schools are eligible for funds under several general health profesriora 
education authorities, inclxiding: 




o the f «derally-*iji6urBd HEAL Student loeui Ptogram 

o «lmtiGnal assistanoe to dindvantagfed students 

o health pcofesslcns special initiatives (grants for qpecial 
pnr)ects in anas such as health pronotiai and dlflftase 
prevention; curricula develcpnait in health policy, clinical 
lutrltion, and tha appUoation of social and behavioral 
•ervioas to the study of health caie delivery; the 
develo|iDent of nechanims for assuring the ocspetenoe of 
health professiGns; the develcpnent of instruction, 
inclining diid^f \ affiliaticns, in geriatrics). 

Efforts to assess the ispect of federal funding have been stymied by lack 
of data. As a sajor federal r ep ort on allied health concluded: 

It appears that it [federal funding] added iapetus to a 
trend that was already underway • • • mch of the private 
sector growth in ertmatlonal programs that occ ur red between 
1966 and 1971 without allied health grant si^port may have 
ooc ur ra d in eoqpectaticn of federal assistance. Quite eqpart 
froD the question of the relative iapcrtanoe of federal 
support in increasing allied health manpower output is the 
prtblen of determining what the inczease %ms and where it 
occurred. Vriar to establishnent of a federal role in 
allied health marpower, there was insufficient interest in 
the problems to allow the collection of data en educational 
programs. Not until 1972 was reliable information obtained 
on the type and amount of training offered by colleges and 
universities. Sens collegiate pr o gram growth occ u rred at 
the expense of hoq)ital-based prograios and cn-the-job 
training, another factor for which there are no reliable 
data (U.S. Oepartnsnt of Health, and Welfare, 1979). 

Other segments of the federal govemnent have also played a rde. 
Ihe Health Oare Financing Admi nistraticn, through the Medicare program, 
has provided support for clinically-baaed education. The Department of 
Education has helped throug|h its role in general support of higgler 
education loans and s^larships and in its qpecif ic rde of 
voc^tionalHbechnical training. The Veterans Administration and the 
military services have also played a part in training the civilian siqpply 
as th^ train for their own personnel needs. Finally, the Department of 


- 23 - 

Zabor has bMn oano&m d %ilth «itzy-l0vel oocupatixxiB having offered 
trainingr through the Qcqpceheniive EkqplcyMnb Tkaining Act (CEIA) program 
a*id later Job Itetnerahip and Tkalning Act ( JUA) . 

TAMJ SAi Division «f AnocUtod ind Don i Ntlth rrofmlom^ •rantt, Cooptratlw A g rt — nt s «id Comractt 
§mrM In tHo Am of AUM Ntftlth, FIteok Yoors 1967 tftrouih 1966 

Plsoil Ad^mid Trtlnini tptcUl i^lol SmIc 

Yoor TrtlnoMhlp ffwtltmoo li^rvvmnt rrojoeti li^rvvwnts Othtr Tottlo 


6 HI ,977 

6 0 

6 0 

6 0 

6 5,265,000 

6 0 

6 5,526,977 






































































































508, VS 




































6n,602 ^ 






^ rrlor to 1989, tho Dlv^ofon moo known oo Olvlolon of AooocUtod Nooltli rrofooolono. 

^ ttlooood l^potfM ftndi. 

' (CDINC oooporotlvo M foown t ftftdi. 

^ Utmit for oUlod lioolth porsoml in hooUh prawtlon ond dioooot provmtlon. 

' 6r«id total InelMdoo eontroct OMord anunto. Controct MifM oiar d id by floeol yoor or« not ovoUobio 
•t ttilo tlM. 


- 24 - 

Pia stata Holm ihioug^ ttielr invDlvonent in hi;^ adbcation financing 
and raguloticn, states ars a aajor fbraa in cktandning the mriaer and 
distribution of alli«S tealth prograiiB. m 1976 (tha last year of 
ooqplatba data) , 71 panamt of public ooUaglBta instituticns had at least 
cna allied healtii progxan, but only 36 percent of private schools offered 
allied health edocation (Hational Oon&ittee on Allied Health Education, 

The pcqpansity to invest in allied health sducatien depends in part 
cn the health of the state's eoonxiy. In one of xtu noctahops the 
ooonittse eaqplorad decision »)cing in three states— Texas, Illinois, and 
Hstf York. Iteticipants indudsd npcesvitatives of higher education 
coordinating authorities, gmeral ooUegiats adhninistzatcra, and allied 
health school deans ttm diffemt types of institutic«. Oiey described 
decision saking and a snse of vulnwability that was related to tiie 
•ooncndc health of their regions. 

Allied haaltii yiuyiam aAninistrators in Texas, where tax revenues 
have bean falling due to the declining oil industry, felt at greatest 
risk. The Texas allied health eduoators believed thenBelves to be the 
first line of defenee against ssdical school cutbadcs. 

Ihe eoononic situation was scmeuhat better in Illinois, but overall 
state hic^ education cutbacte were farcing state college systms to plan 
hotf to xecpond to budget outs if a pending tax incraaae did not occur. 
GM school systan, having already raised tuition the previous year, had 
directed its deans to ocnsider the iii|>lications of a 5 peroant budget 
reduction. Ihe cptions available to me allied health dean included: (a) 
not filling vacant faculty positions, (b) offering seme oourses once 
instead of tkdoe that year, (c) canceling planned equipnant purchases, and 
(d) dcsiiig the school's physical therqpy program, which needed aore 

At the tine of the woriahop. Hew York State deara and policy 
officials %iere not focused on budget cuts fbroed by the states' eooncnic 
picture, but on the state's raaponsibility for ensuring an adequate simply 
of health care persomel. A state health departiBMit task farce had 
recently been fanned to eBq;aare *Mtical ahortages'* in nursing, heme 
haaltti care, and physical tiierapy services. One issue pronpting task 
force creation was the inability of state chronic care facilities to 
recruit tiaarapists. Deans attanding the connittee's wortahcp identified 
faculty ihortage as a aajor ispedioent to expenilng education piujiaua* and 
enroUaants in physical tharaK' and ocnyational therapy. 

State^wlda planning fkequmtly occurs vndar the aiiqpices of state 
hii^mc education ooocdinating bodies which have raaponsibility ftar 
Improving iwv eduoation pvogcans. m evaluating nev progran, the 
ooordinating bodies oonsidBr such issues as geogzaihic nldistributicn of 
progms and practitionacs and the iapact of new p tugiai a B on Binority 
participation. Decision aaJoers «ho participate in this policy arena often 
■ust be reconciled to the fact that the politics of hiipu education 
planning (deciding, for eBanple, which anong oonpeting iivtitutiora tfxsuld 
zeoeive the nev program) aay not lead to the ccnclusiora thai- oeke the 
aost e w sa fkosi a heb. i planning stand|point. 


Statis cqphaslze different valiies in their reviev of criteria for nev 
poregnsDB. Ninouri notes that its 

8tat»^iide nvima is principally interested in the state's 
need tar piuyiams and eervioes, and resoutoe allocation 
issuBs. Ihat is, Mm statewide need for particular 
piuyiaas and the q p prcnti ate wans of financing these needs 
to assure Miseouri^s citizens financial access to quality 
educational eoqperience (Minouri Coordinating Board, 

In contrast, Itaas has stated that 

Ihe expenditure of public tax ftmds fbr educational 
p r o gra e a in any ooofiational area is a aatter of public 
pdlicy dirbcted at nesting a public need that cannot or 
vlll net be wt otherwise. Student interest is not the 
aajor conc e rn for eoqpenditure of public tax funds for an 
occupational training progra m (Allied Health Bduoation 
Adv^isory Comnittae, 1980) . 

Ihe ability of state coordinating bodies to enforce their resource 
allocation policies varies. Sone state authorities my only be able to 
apply jawboning tactics to influence institutional decisions. In seme 
oases battles are foug^ in the state legislature's hi^mr education 
budgeting process— a specific line-iten request for a nav program, for 
exaqple. Depending on state political tradition, legislators say cheese 
to wield influmce in favor of oonstitumt education institx^tions and in 
r es p o nse to lobbying efforts. Host often, however, the survival ot allied 
health piugiai u s is faroug^ into question %tan anartamln institutions find 
themselves foroed to reallocate institutional leeourooc as a result of a 
budget crisis* In sone states, Idffmc education coordinating governing 
bodies have statutory reviev pouers for nev prograns. 

The Rrivate Sec±Qr Bole Ihe private sector role can be seen in the 
activities of aocxediting bodies, professional associations, and 

Aocajaditim Bodies Ihes:^ are a nultiplicity of issues surrounding 
iiho should oontr^ accreditation, hov it dmld be structured, end lAiether 
it could be a less costly process. Ohis discussion, however, vill focus 
on accreditation standards, idhich have a sajor iqpact on collegiaite 
decision saking about nav or eoqpandad prograss. 

Ptogram ackdnistratoors oust take into account the cost of CLLiplying 
vith the standards of aooediting bodies and the r aoc Mutad atioM of site 
reviav teans. For exanple, pr o g r ans scnetines dose because th^ cannot 
■aintain student-faculty ratios, equipnent, or space required by the 


• 26 - 

aoczBditing body. Qftin then im a clash bstwe^a the aocraditing body 
(vhich ballovQO its •fiamtials assure basic niniau standards) and 
gemralist aAdniiArBtors (%iho see sitie review reocDraenlations as 

a tool to be iised by der^artsntal chaixnen to get more support for their 

_ jrjB RistoriGally, wuA of ttm adkication 

activity of allied healtix pvyts^iaml associations has been in pronoting 
the ^ft of sdixaKtional pty^aas fkta hoqdtals to arwVmln 
institutions. Qnoe aooospliihed, interest often omtered on raising the 
entxy^IevRsl of the professim mis/at cxeating assistant^level categories. 
Today, associations^ education ectivities range mm %.ldely. Ihey ad^t 
include ocnsultation to eoadeaic institutions omtenplating nsv prog ra m 
offering, vockshaps fdr edninistxators end ftaulty, student reouitment 
programs, end tim aaintenance of edition datdbesee. It should be noted, 
however, tt»t not all allied health fields have %fell«-orgpsiLzed 
professional associations vho can engage in education activities. 
Sqpplwmting the vork of {«£ofeBsiGnal associations are the Amarican 
Society of Allied Health Ptoffesiom and the National Society of AUied 
Iiealtii--tiro organizations that cut acxoss disciplinary lines in an effort 
to he]^ their nnterB addrees education issues ocmBon to nost fields. 
Accreditation reqponsibllities for dietetics, physical therapy, and 
qpcftcfa l anguage and hearing are handled througlh independent entities 
oi^erating in conjunctim with the professional associations. 

Be cau s e of an extensive literature, and activJ,ties of the Federal 
Itade Ocimissicn %dth regard to the role of the Anarican HedicEl 
Association in eatten of physician siqpply, it is reasonable to raise tiie 
question of idhether allied health associations influence supply, 
restricting entry as a aeans of enhancing the eooncmic status of its 
ambers. An investigation to determine such influence, however, vaB 
beyond the scope of this study. 

Rrivate Foundattms Oonplenantary to the rtd.e of federal and state 
support is the contribution of philanthropy in generating coqperiaients in 
allied health education. Principal aonong the foundations is the W. K. 
Kellogg Foundation, lAiich ^y&r mrtf years served as a spur to 
institutional developnent suiJ JiMderahip activities, and to studies of 
allied health fields, currently tiie fbundation is siqpporting a clearing 
house at the ttiiversity of Alabasia to darify and pranote the ooiK3ep t of 
aulticoapetency in allied health and support several activities of the 
Aaerican Society of Allied Health ftofessions. 

ItV is Allied Health Bduoetion vulnerable? 

As tim pnvioLS section's reviev of federal, state and private rdes 
indicates, the era of direct efforts to eoqpand the allied health education 
enterprise has ended. Yet, thB da^^to^y business of federal, state, and 
private decision aekers ccntiny!^ to she^ allied health education. 

- 27 - 

FWeral Madlcai* zviatJurMnent policy, state higher «lucation fcudcretirg 
and ragulaticn, intarast groups pursuing anhancsad parofasaicnal status, and 
•ducaticnal aocxsdltation ara all pcwerfUl influnoas cn alliad haalth 
•docotijn's ftiturs. How stabla aducatifln institutioni wiU ba in the 
future will (tapend cn their ability to ocBpeta for higher aduoatlon 
xvsouroes vith otter aora a nUwUiaJ aoadadc piuyiaim whose graduatas nay 
also be in hi^ dnand. 

iteinfadninfl Gr nir^ ^" M^^^in A WBber of prestigious institutiens- 
Oiiversity of Fmylvania, Oiiversity of Middgan, Bury univarsity, and 
Stanfocd Uhivsrsity, for maafUm-im closed allied health schools and 
pcogrw. A ftBxSBMntal ocsponfi t of the raticneOe ftir cOosura appears to 
have been ttet the ponpa ition of aUied health practiticners ddd not 
sufficiently oontribuba to the aapixations of a x asa mJi university 
Making to oanoantxste its lesouroes in areas of strength. As allied 
health deam see scne of the aost notauortlv programs close, they grew 
unratoemive itoxt tte future of their own prograns. Ihey are also 
cc^ jemed dwut the fixture of allied health prograns because the prograns 
lade tte CBfiacity to foster [ wiiwiuli and produce teachers and aoademic 
leaders (Hidridc, 1985; EraJci, 1985). 

Althou^ it is difficult to docunent tte fragile condition of allied 
health eduoaticn, tte oonnittee believes there is acne basis for tte 
dea»' ifpnteniian. FUrthamoLC, tte ccnnittee is ocnoame d that 
closuies have signaled to acwlmlr decision nekers and public officials 
alite ttet allied health education my not te a scund investnent for 
edocaticnal dollarB. 

As Tw M ** 5.5 (baaed on 1970s data fron tte National Oonmission on 
Allied Health Education) danonstrates, t «e prograns long eidsted in 
alnost every type of ooUegiate institution. Ite connittee believes ttet 
there is no gmeric or iiterent quality that disqualifies allied health 
education fktxn life cn aiv obbius in tte nation. Ite diversity and 
•voltxtion of tte warv ocoipativa suggests ttet scne are aora nitad than 
others to varios aoadanic settinga and degree levels. But conclusions 
draun today adaout a given field nay change tcaorrcw as toxwledga and 
practice evcOve. Each type of collegiate setting has its advantages and 
disadvantages. Gmarally s^Mlclng, for ascaigple, acadeadc health science 
canters have easier aooees to tilinical reaouroas and a vide range of 
cnartudtias ftar InterdisciFlinary esqpeciances. Sowever, as reported 
to tte ccBBdttee, tte latitude for decision naking and creativity of 
pcograa design by dc^ and pcogrsa diractcre has traditionally been nare 
Tl f«i»^ in acadesdc health science centara than in echools of allied 
health that are independent of such centers. Ocanunity cdllegae ahine in 
their daility to Mxket to diveree student populations ito ara 
job-oriented. Bdication there is tailored to suit tte needs of encacyers 
and students in a given local oonnunity. 



TMU 5.5: Nrctnt of CelliiUtt InttltutlM m\th AUM NMlth ^roen 
ClMsff Icatlon of Inttltutlml Typt 

iuMbtr ond rtrcont 

rtrctnt of 

Totol Nuiter of 

with Alllod Htolth 

All lid Ntolth 

iuch intti tut lorn 


^rogrM In 

Typt of Inotltutlon 

In tho U.$ 

iifter rtreont 

Such Inttltutfona 

Loading «fif¥irsttloo fn tofw of fodtrol 
f tnonclol oiwert for oeodoile oclvco ond 
•Mord at loiot 50 ni.0.o omuillr (ond N.O.S 
f f Mdlcol ochool on tiio om cwpui). 





tooaarrfi UntwftI- II 
Aflono tho loodfng 100 fnotftutlono fn torwo 
of fodM^ol f Ininelol oi^port ond OMord ot 
loott 50 Mi.D.o (ond M.0.0 ff appdciblo). 





OoctoroUCrontlna u^t^nltlat I 
Anord 40 or aoro Hi.O.s (ond M.O.s) or ro- 
colvod ot looit 13 all lion In totol fodtrol 
oioport fn oltlior 19169-70 or 1970-71. Mo 
fnitltutlono oro Includid thot iront foMtr 
thm 50 Mi.D.0 (or (M.O.ol. 



Doctoral -Cramlno lMlv#r«IH«> H 
fnitltutlono OMordIno ot looit 10 Hi.O.i 


Cowohonilvo l^jyi^ltlaa and CoUaaat I 
Initftutlono offorino o Ifboril oru preorM 
md oowtrol othoro (i.o-t onofnoorlno* builnoti 
a^fnlitrotfon); thot hmm it laaat tuo profit- 
•fonol or occupotlonol pa^Mt* ond onroU of 
loott 2^000 otudwiu. Ntnv htvt attttr't pro- 
nd« it aoit^ Ifaltod doetorol proorm. 





Cofohontlvo laiW^ttfat and CoUaaat II 
Otato ooUooot and tOM prfvott collooot that 
offar a lltooral artt proorat ond ot loott ont 
profotolonol or ompatlonol proorat audi aa 
fiiroini or toodior tralnlno* atlnly nf th o 
fn odueatlon. 





Ufaaral Artt tiAlm^ I |26 
Nl#ily oolootlvt . mum thi 200 loodli« 
faoceolourooto-ortntlno Inatltutlont In ttrm 
of ntftert of orodMttoo rooofvlng ni.0.t ot 40 
loodino 4Ktoralfrantlnt fnttltutltnt. 

Liharal arta giitt->> II 474 
Otiiar Ifborol orta colltooo* atny of Mhldi 
oro ORttntlvtly fnMolvod fn tttchor trolnlr«, 
orontino dtoroot fn artt and tclmia rathor 
than In adueatlon. 







oontfnuM. . • 



TibU S.S CContlnutd) 

typt of Initltullon • 

Total MMter of 
tudi lnat1tut<ona 
In tho U.$ 

Nuifear and ^aroant 
irith Alllad Naalth 

All lad Ntalth 
yrogr— In 
•uch Inttltutlona 



iMQ^Mt ColtMM and instftiitfons 





and Othar Inatltutfana Of farina Daoraaa 





Madleal tehoota and Nadfeal Oantara 
tneludM only thoao Hiat ort Hatad 
aa oaparoto caa^puaoa In UME Ctoanino 
fall Enrollaant. 





Otdor taoarata Maalth rrofaaifonal 





Sdioola_Qf^no1naar1na and Tadmoloav 
Tachnlcal Inatltuclana art Ineludid 
anly If tliay OMard o faachalor'a dtgrat 
and If thair prnrm la IWtad 
OKcluilvoly or olanat aRClualvtly to 
toctinlcal f loldn of atudy. 





tehoota of iualnaaa ItananaMnt 
Includad only If thay OMard a bachator'a 
or Mfhar digraa and If thoir prosnn U 
IMtod oxelualvaly or almt axcluafvtly 
to 0 builnaaa currloului. 




td>ocla of Art. ttolc^ Daalan 





kimli fff im 




Toachara Collaoaa 





Othar teaclallsad Inatftutlona 





Includaa tradiato oantara, attrltfaa 
oeadnfoa, aflltary Inatltutfana 
(lacklm o llbaral orta pro0raii), and 

iOURCix Tha Futuro of AUfod Naatth Cd^atfan: Urn Allfaneaa for ttia 1900a. Matloml Oenfaalm on Atlfod 
Itaalth idMcatfen. 1980. 



30 - 

To guida inBtitutions daciding whether to continue or start allied 
health adkication pnagrans the Southern Regional Bducation Board suggested 
that the fbUowing questions be considered: 

KiaifiD* Z* the pLugia m consistent %dth tiie ixistitution's philoscphy 
and purpose? 

BasdSSBtS&i will graduates be able to secure enploynent and will 
that aDDploynsit satisfy the local, state, regional, mO/or national 
adssion of the institution? 

ACCZSSltatlfiD: Is thm institution willing to invest in a program, 
given the rasouroe amafAian iiqplicit in achieving aacnditatian? 

filaika&i: Will there be sufficient enrollBent oveo: a sustained 
period of tine? 

ft l l^ jT rtflTY o mme i i ia s Is the institution prepared to adopt pnuyiaiub in 
which clinical ouu|XjniaiLs nety require equipnent, sqpervision, and costs 
that crften eoooeed those of other types of acadonic pcograns'' 

CBOll^: A there a sufficient faculty pool to draw fron and what 
zesouroas will be neoessary to attract qualified individuals to teach? 
(Halona, 1980) 

Ibday, allied heq^th eduoetion appears vulnerable on all but the 
"•nplcyBMnt demand" criterion. The loey to iupcoving allied health's 
bargaining position in aonimin is to dononstrate value to ihi parent 
institution striving to fulfill its aissicn of scholardiip or ocnnunity 
sendee. Ihe reconBandations that follow are designed to address some 
problems that prevent allied health piuyiaius effectively conpeting for 
institutional resources, thus endanc^ring their vizibility. 

Faculty aiartaciBs Because aary allied health fields are relatively new 
to collegiBte environmnts and have grown rapidly in the pest decades, 
educational piugiaius often faoe both quantitative and qualitative prablans 
in filling faculty positions, in {hysical therqpy, for mansiLB, the 
luriMT of accredited univaocsity prayiaas grew frcn 413 in 1970 to 113 in 
1986. lha sifply of faculty appears not to have tapt pace. A 1985 survey 
of nrnAmir. adninistratcrs in these pmyiaiuB repoctsd a need for 152 
additional faculty siai^y to Met oumnt donands (Am, 1985) . As a 
result, aany piogiaas rely heavily on part-tins lecturers without regular 
faculty appointaaents, on flBOUlty fron aciantific disciplines who do not 
hold profasslonal qualifioationa in the clinical field, and on 
professionals vho lack the acadaaic credentials traditionally mrr4-r1 of 
university faculty. Itr eoceBBple, in its faculty survey. Am reported 
that only 28.2 peixjant of fUll-tiae faculty in physioal tiwrapy piogiaiiB 
held a doctoral dagrae. ihis is in dear contrast with national data that 


itckr 54.9 iMKoerir od all fmxlty teaching in institution; of higher 
•ducstion hold che dxtorata (Qmiagie Foundation fbr the Advamnent of 
VKdiing, 1985) . Becxuitaent of qualified niv faculty is Mriously 
b;afKKA ty ttya very linitsd pool of candidatM. Even relatively nature 
occupations 5uch ui oooitational and phyeical tiwzapy report that only 
About one peixant of all xaeten hold a dcxrtonita degree, and jiot over 24 
paromt have ■astar's deyraee (9Prh, 1987; AOdA, 1987) . 

m a auLvay of 124 aadioal record education piujtaMB (over 80 pexoent 
of all i M-utftaiwi ) . t he ■ajo rity afdoyed only one or two additional f&cult^ 
jmbera beaide the prognn diractor; no pcogran had aotra than fbur 
ftiU-tiae additional fteulty. Only five directoca in these adnols had a 
doctorats. Mmg the S3 fUll-^tiae faculty Mnbars in universityHaaaed 
FcogxaoBB, only 2 pn eee e ei J doctocatee, 33 had Bastar degrees, and 18 had 
baocBlaureatas as their hlgM«t anartmlr degree (Jtant^akul, 1987) . 

Although aona allied health profesaionals are enrolled in mster and 
doctoral degree prograsa, lade of financial aid and thn relatively low 
earnings of allied health clinicians foroe aost to do thia advanced study 
on a part-tiae basis over a long period. Lade of funding has alao 
oonstzained the developent of graduate pmgiaiMt in acme allied health 
disrdplinee. Althou^ advanced stud/ in related disciplines sudi as 
physiology, psydx»Iogy, or edition benefits allied health faculty, the 
lade oi graduate pmyiame in their own disciplines has liaited tt» nadber 
of allied health faculty %iio are active ednlars in the field in vhidi 
they have the greatest teaching reepcnsibility. 

Gpticns for producing f acu ty efficiently ihould be taqpiani in order 
to nasdnizit faculty developoDent rescurcee. Ohe American Ooopational 
Therapy Asuociation has had acne auocesa with targeting teculty 
developmnt efforts to dinioal faculty vho aig^ be inclined to pursue 
full-^jae teaching ai:pointnents (nneaeller, 1987) . Another approach 
wuld be to focus attention on straanlinal allied health certificate 
ptcjc>iaiiiB that give individuals vith Ih.D.s in other aoadanic discipliiws 
thr. opportunity to gain a practioa credential fdr Vreaching purposes. 
nalcxsab (1987) describes a pertnenAiip between Baylcr College of Ife^cine, 
Vexas Am tftiiversity, and the Uhiversity of Houston ti>at offers ^rograne 
in allied health teacher education and adainistration vMc^ rave been 
productive in si^plylng faculty nationwide. 

Ihe rationale for a federal role in faculty developnent in allied 
health is sinilar to tiie justification for federal support of family 
practice piujxam in nedicine. Fkon 1972 througlh 1984, fUeral grants of 
over $200 Billion fostered the growth of graduate family medicine training 
activities (Healtti neeauivee and Services Adainistration, 1986) 

W» allied health, family medicine exists becauee the federal 
yuveiiMMi t vas willing to prtncte a ocnoept designed to addrees <a 
Urn health care aystan's deficiencies. Ae a new endeavcn-, family medicine 


departaents lack qoalifittd Acuity and the Ability to gamer ithhiiii Ii 
ftmds ttm txaditicnal acuioeu such as Mm National Iistltutas of Health 
(NIH} partly baaause of non-ocqpetitiv* sasaaich cxvdentials ancng 
fiaoilty, and paxtly baoauaa of the lov funding prioority of prinxy care 
zasaarch. Wat allied health, fSamlly ■adiclne has yet to pew itself to 
the estcdalialnent st arwlmir atdical ontsKs— « task that is ijiiibited by 
a veistMrsaient systa that does net geneFally zeuaxd non-ptoo b dure- 
orianted fiaoulty practice. VWeral grants are used to nke the playing 
f iaO d aoajB level far fandly aedicine in the oonpetitive aedical school 

Federal invastaent in family pcactice is based cn the policy 
awnnwemnnt that prisaxy care needs are lanat and that thess prograne are a 
cost-efficient aaans of pcodoeing and distxibutlng prioary care 
practitioners, siailar national goals regaxdixig rshabilltation, disease 
prevention, AIDS treataant, and geriatrics can be «iell-served by sm»rt 
of allied health aduoation. 

g» COaidtttC imilHMlto thit thft ffrtwwl nrwenwent: and mt^tmn i\mA 
faculty devclcaient cnanta in allied ho,»1t>i flrl ^te. esneciaHv %hcre 
faculty availability and lacdc of cllnj^] fflgTfTt^*^ InhlMt the ptoduehton 
of antrvlevel praetititanere. 

Ih its final rapoct, the NIH task fotoe concluded that the extranural 
and intemural pcogram activities then 8i(:parted by the NIH vere 
consistent with the NIH's aissicn and that achxiies condi«ted with nurses 
as principle investigators and studies designed to inprove nursing care 
(but not necessarily directed by nurses) could be fostered thxxsugh a 
oabination of activities. Ihese activities were intended to assist in 
training nirae researchers, to encourage greater coUabaFation and 
interest of aedical scientists in interdisciplinary work, and to ertiancx 
the capability of nurses in oogpeting for lefiiwiiih sinpart (National 
Institutes of Health, 1984). 

Although data are hard to cone by, the status of the research 
capability of nost allied health fields appears to be less developed than 
in nursing, m part this nay be due to the fact that nursing has had a 
continuing ccnnitnent to research front ""he federal NUrse Training Act. 
Oovey and Burke (1987) , vrlting in the Journal of AUied Health, offer an 
additional aaqplanation: 

qualified faculty by the traditional standards 

vere not available, selection of our University faculty has 
often been largely ftcn the practitioner ranks and fron 
those %«x> had perhaps acguired graduate degrees in such 
unrelated disciplines as education or adhBinistration. Ohe 

' - 214 

- 33 - 

fbcus of their txaining has been on technological oenijetenoe 
and, in acme cases, diacdplira pedagogy but has not alwsys 
induSed xesearch. virtue of their oiiin training, deans and 
directors thaoselves are often unable to develqp the junior 
facul^ and, in fact, too aan/ deans and ^iityiam directora 
either lack an understanding of cr 8iDi)ly ignore the tripartite 
acadnic adssicn. 

In later chapters of this npoct dealing with issues of health care 
legulation, and long-tazn care, the ocanittee notes decisions 
ttiat administrators, payers, and regulators aust adoa in the abacnoe of a 
nmmmli litacatuxv in allied haalth. Nadioal scientists and other 

ieseimlieiB on their own will not, and can not, define lee h priorites 

OBong taaal'Ui sendoas deHvary issuas or the dinioal agppllcations that 
^ioally oonoem allied health ponctitioners. AltSnuc^ nadioal 
acimtists lixsuld be enocuraged to develop oollegial relationshipe and 
undertaJoa joint projects with allied health personnel, they are not likely 
to be as inberested in the outoone aeasurwont and oost'-ef f ectiveness 
^t naed to be addressed as are thoaa vho deliver the services. 

Allied health fields vary in their aaturity wi^ raqpect to a 
pcoductive ieeiiim ri capacity. Some fields, such as dental hygiene in 
which aost practitioners have lees than a baocal aureate, are only now 
baginiing to eoqilore the poeeibilities of a cadre of inwnimli leaders to 
>^i^^A a body of knowledge linked to a theoretical fkaneMock. Ihis 
lewemi Ii Aiould go beyond sinple unrelated pilot studies. It should 
define dental Iiygiene as distinct fron dentistry, and eoq^ore the 
efficient of aathods and nodee of practice (Bouen, 1988) . In contrast, 
other fields like ^ p oo ch-language patiioiogy and audiblogy have nany 
practitioners with naster degrees and doctarates and a rich history o£ 
tqpping into a grnring knowledge base in human oonnunication services and 
disorders. Both fields, hcwever, Aare a oonoem over the lade of 
relevant research that finds its way to those providing patient aervioes 
whether it be to the ocnnunioatively ispaired (Zudlcw, 1986) or to those 
seeking preventive eervioes fton a dental tygiinist. 

ft mtn 

iiwhitiitiens with strong, 
ptsxn. 'n s that 
jcaaMiienrls that 

Lth practice. 

Try fmiipll^ 


talented liy<W<i<ii»l. 
fttllfMBhip HFoarm he develccad to 


- 34 - 

Mnaneina CHInliml ftl^lTfltiim 'Dm dosing of hospital education prtjgrans 
<ti«nwfMfi Mrlitt: in this chapter nprasents nore than a long-^tem shift 
frcn hoqpitalHbaaed to arMminnl ly^asad education. Hospitals with 
linited zesouross aay zeduoe or elininate clinical affiliation with 
education ptu^aait as well as closing their own qponsozed progranB. 

As clinical affiliates t^ttmipt to tria their costs in xmpdve to 
raduoed tmrnum, eduoaton fiMr that hospitals will zeguMst zmneration 
for the scfservisifln of studsnts or sesk other Mans of shifting costs bade 
to the education institution. It appears, as of 1987, that this is not a 
large problflB. Mian GAHEA qMried eduoation diractcrs about changes over 
the past three years in the costs of the dinioal portion of their 
pcograns, the dizectors r ea pmrled as followB: 17 paroant said they had 
esqperienoad significant cost inczeeses; 13 peroant felt that program 
viability wee threatened; and 15 peroant pazoeived that the progzam had 
beccne a burden to the aponsoring institution. Only seven percent noted a 
significant change in ourrkulun (CMlEA, 1987) . Allied health educators 
aze also conoained about long-standing proposals to ooiBtrain or eliminate 
Hadicaze payments for education. Madicaze cuzrently pays hoepitals for 
the dizect education costs of allied health p pc g rams on a veaaonable cost 
basis as an addition to the HC (Diagnosis Related Gzcqps) peymesit. 
Bayments are intended for prcKfldez^-operated ptogiam and not for 
affiliated prograos in which the hoapital provides part of the clinical 
training. Ibr the latter, the costs and benefits to the hospital aze 
presumed to balance one another. Sinoe the passage of the Prospective 
Riyment System (FPS) , there has bean scne confusion over ^tether the ccsts 
of jointly-eponeored piuyiaua are eligible for zeinfcureeBait. 

Rneidentlal budget proposals to tezninate Madicare funling for 
hospital-based allied health and nursing education progr a ms has added to 
the ccnoazn that hoqpital financial managezs, loddng for every 
ofjporttmity to reduce institutional costs, will eliminate clinical 
affiliations when feasible. To those attcnpting to find new aouroes for 
federal budget reductions, tiie dizect education pass-'througth zipresents an 
o pen-ended ao^enditure insufficiently targeted to the most ijiportant 
national maipower needs. Most often, this is thought to be the need to 
develop greater naiberB of primary cave physicians and fewer qpecialists. 

In attanpting to aneeen the iapact of proposals to eliminate 
MBdioave's education auRport, several zeoent actudiee aponsored by the 
Health n eeo uroop Kid Services Adoinistzation have generated a better 
understanding of the vole that this source of education financing pli^. 
A congvaesionally mandated stud/ of nuzsing and non-fhysician (that is, 
allied health, as defined fay the study) costs in laoyiamB approved fbr 
Nadioave veiabuzeament, conducted by Aisplied Nanagenant Services, mc. 
(M6) , VBveals that together these ytujiams cost Medicare zougjUy $226 
million in the second year of proqpactive paynant. ihis figure is 
relatively anaU ccnpared with the $42.7 billion the govemnent paid to 
hospitals under Part A Madicare for the sama period. Analysis of Medicaze 


O08t reports inlioate that non^physician health oducaticxi prograns oost 
the 514 pctviders in the program a total of $167 adllion.. NUrsirg 
■ ytujiaiub wra van eaqpensiva, costing 547 providerB $533 nillion (HRSA, 
1987) ; Hadioara pays Gnly for its own than of the allowable direct, 

Other studies (Lawin, 1987; Itathonatioa, 1987) have oonfixnad tt^ 
Gfaeervaticns of MS in their interviews iidth directors ol hospital 
sduoation prograns. Bdocatican pcograms c Ter mnarous benefits to the 
enplqyer, chief of iliich is the qpportunity to racxuit future «qplGyees« 
ASditiaial iMnaf its incaude sotivating existing staff to stay curvent vith 
advanoas in their field, and enhancing the reputation of the hospital by 
prc^dding a ocasunity servioe to local eduoatiion Instituticns* 

DHpits theee benefits to aployers, precipitate action to cut 
Medicare's edmtion sinpcrt runs the riek of destid>ilizing vulnerable 
allied health education prograns* Ih the CGnnitbee's view this is not 
laactti relatively ■nail, dxart-tem budget savings* m the long run, 
Madicare beneficiaries would be harmed by limiting clinical eogperienoe for 
students* Moreover, asmy of these costs are liJoaly to narge later as 
potentially sore costly recruitannt and on the job training eaqpenees* 

Iherefoce, the QOBinlt±ee reocmngnds that until credible alternative 
apDPoadies are dsvelcced, the federal anwrripent and other third-carfcy 

r11n1r?n1 tlirfitlTr 

Pie Qanaaratlvi^ ppfft 9f ^^^^^ W'^^ith BEtotion Allied education 
programs are paroaived by education planners and adndnistrators to be 
hi^^i-cost programs* As a oonsoquenDO, they can be prima targets for 
institutional budget reductions by central administration* liiere state 
hi^lher education funding f omulas do not ocnpensate for these hi^ier 
costs, progra m s are exceedingly vulnerable to cost cutting SMsures vhen 
times are hard in hig^r education* 

In an effort to better negotiate %iith central admiiiistration, there 
has been a growing interest in constructed cost models to help allied 
health deans and p ro gra m directors eoq^lain why their unit costs ai&y be 
hiq^ier* Iheee models fbcus on key assunptions about faculty contact 
hours, facul^'-student ratios, resource rec]uiments for dinioal 
experiences outside the dapertment, and fteulty ealaries (Fkeeland and 
Gonyea, 1985) * Although ttm models are useful tods fbr improving 
efficiency and then dnonstrating ttiose iapcovenents to 
administrators, eaqdanation does not change thm reality that allied health 
edLKsation is faculty intensive; it necessitates clinical education 
eoqperienoes reciuiring coordinBtion and superviaion; and it often has 
eoctenaive laboratory and qpaoe regairenents* 


- 36 - 

alTMdy Bade in this diaptur will telp addx«ss 
allitd haalth pinyiaiiw hav9 in ooniietlng for 
. but ttMM MBKirM an no wfastituta for actlcnB bbii^' allied 
hMdth Khobls wjtt bagin to take to gananta the ravanue naeded to 
thriva. Nadical KhooLa haw Incxvasin^y ocae to raly cn InocBBs 
gmaratad tvm faculty pcactioM. Although such activitias ny not 
aFprcpriata or financially advantagaoua tac aany alliad health fields, 
tiMy uy be so fior acna, if thiy are aatabliihad with aufficivit 
fatathou^ and aaqpertiaa. The notion of gmarating ravcnaa hy pccviding 
MTvioM neada fUocttwr aoqploration, howavar . Sarvioas panvidad night be 
adboational (aoetansicn o o ur aa a or adult aduobticn, fbr axanDla) , cr nay 
involve imovativa ralationriiips with industry. 

St^itv Of alllad health TWtlTTml 
the teieHnan Se^it/t^ of XIUmA Wm^^th Pmfeag<eng 
Aatlen fiar Allied Haalth ehaild <n»,»^f^-<«»»^ 
mrmtffifld i" hma denlm their 

and Indiwtiv ralatienehipa. Thoaa niH;<r«n| 

^ Mia hr^lA i*«iffihm to help Ingtifail^li 

^hm inrAi« mr^ fllimfinlnntfr Infmrnrinn 

In undertaking rsvenip ganarating anterprises, however, allied health 
deans will oonfkcnt, and poasibly asaoatbata, a problen they have faced 
before. Faculty xaaouroaa ara stretched thin in order to control costs, 
and the aooassiva teaching load leaves little tine for faculty to engage 
in scholarly activity, .rasearch, and college connittee work. Ihese 
activitias, howevar, constitute a najcr portion of the traditional 
evaluation criteria for faculty pronotion and tenure. Ihey az«, henoe, 
the praferzad non-'taaching activities pursued by faculty %iishing to 
advanoe their career in aoadmi. Maintaining state-of-tha-art clinical 
ocni)etence aust ftirtiwr add to faculty'a already exoassive worklotvJ. 
Indeed, the connittee heard deans ocnplain of the difficulties their 
fteailty Mntera face in naintaining clinical akills and of the conooniitai^t 
iai>act of this on praparlng students for the labor aerkat. 

To ensure that faculty's clinical ooapetenoe is uintained, the award 
syBten oust be nade to acocnnxsdata clinical oaepe^enx, becausit ft»ilty 
allocate %tat little tine non-^taaching tine they have to those activities 
that are hi^y xmmrOaA, Ohe oonmittee l aaou uM nJ s that institutimg 
Pfferlm alliad health aatdmlr nrnarania wmr j and mncanrt^ faculty 
dinlcwl nametenoa. Clinical nractlcae tha t sustains thin faencetencae 
■^'ould be n riTTillrmiRnt; PPanotlcn . 

It is n0taMDrt±y that this oonoem About the reward system is also 
ons that nadical aducatora have had to conftont. As the president of the 
Association of American Medical Oollages has cbaervad, ••despite the 
realization that taachar-clinicians are essential ingredients of " Mi ^^ l 


facilitias, th» med is often not xeoognlzed tsy the pamit imiversities 
OiQM >«i»intnnt8 and pconotion policies Isavs no niche for the 
dlnician-tascher to zsoeivs proper reoognition" (Peteradarf , 1987) . 

Ftifiaring Stailants Fbr Ttnonou's Jdas 

Jn prlncipls, sounA sducaticsn planning would dictate that aoadonic 
inftituticra base their prograD offerings on an underetanding of the 
toxjtfledge, ridlls, and eociaHtatlnn rai]iiired of their graduates, not only 
tar todB^'B health care labor saxket, but for the future as well. By 
«ctmion, stBtflwide bi^/Moc sducation plaining Aould take into aoaount 
tte six and distribution of psrsomel at dif f «r«it educational levels that 
will be naedKl acjces the state. Oonfounding efforts at euch rational 
plaming, faovsver, are a lade of dmb^ signals fkoa the labor aaxkat atbout 
future tawn etioriroe needs, and continuing oontzoverqr about aatching 
edocaticn to Jw nqxLBmmtta of the health oare delivery systcn. 

Reflecting this controversy, an allied health education advisory 
ocnmittae in Texas hi^i^^xtfci & asries of concerns that often wrfaoe 
«hen sucfi groups viev the broad sfjectrvn of aUied health fields (AUied 
Health Bdboation A:./isary Oomnittae, 1980) . l..aee include: 

o the growing annint of narrow qpacialization at all degree 

o the recpiirements of sone professional gra^ for hic(her 
levels of training for the professional entry creientials 

o difficulties with transfer of credits to inplanent the 
career ladder concept 

o the nost appropriate level of training for various kinds of 
allied health pezsonnel 

o differanoes in ptixjia a s needed to prepare practitioners. 
Blaster clinicians, taachais, researchers, and nanagers. 

Ironically, these are omuerns today because in the past education 
iistitutioni ^lave reepcndad to student and «q;>loyer demands. Associate 
degree aid certificate ptt i yia m s were developed to provide students %to 
were uwilling or unable to qpend four years in achod befbre entering the 
WDTkf oroe an opportunity to enter a field where thoee with the traditional 
hi^wr cndmtials were in short aqpply. Aoadeudc health oenters and 
fburwr o611eges, in addition to ocnnunity colleges, souc^ to veet the 
needs of their own and local hospitals with two-year prograns. Students 
with beccalacxeatee in other than health care fields were acccnnodated 
with certificate piuyiaiae ro they could porsue allied health oareerc. 


- 38 - 

Students interested in oareers In respintooy thereqpy, dental hygiene, and 
ndiognphyr «hich are principally of farad at the associate decpnee level, 
are new able to anrall in piutfiatHS that also allov than to obtain 
baoaalauraate dagraas. The result of all this was the qpening of allied 
health oocqpations to a vlder range of participants. 

Bandng aoocBnodated naads of dif ferant student BarioBts aiid 
eaiaoyerB tto were either eoqperimcing shortages in sane personnel 
eateries cr vho ware attanpting to structure their staffing with 
persomel of differmt educatien levels, the education system is now 
faced, not surprisingly, with a state of untidiness that plamerB find 
unoonfoctable. Vtffther nnn>11rwting aatters is tht. growing availability 
of graduate training. Although advanced Jaijieiis have long been eooepted 
as serving to prepare faculty, adninistratora, and researcheni, there is 
greater aJoqpticisB ydtrni it ans to the elevation of a field's cntry^level 
quBlifioations or efforts to develop rpecialities. 

The ocnnittee aclcnawledges this great diversity in educational 
qualifications, but finds that a public policy prcblen requiring attention 
■ay not eodst. Ihe diversity in and of itself is not a prdalcn. ihe test 
of whether apecialization and changing qualifications or standards are 
dysftmctional is tuo-fold: (1) Is there wastefulness in student 
educeition investaents? (2) Is the education systen reepo»sive to 
•ociety's need for a ■arpower si^ply that permits the health care system 
to ftmction efficiently and provide care of the desired quality? 

TM^rmlllTm T^^^-'^Trt, hV fft^rimte Ihe act of opening new education 
pxujraiub and admitting a class iiii>lies a contract with students containing 
certain assurances. No school can guarantee a student a job, nor 
guarantee that ddlls and knowledge acquired will be oarkatable in 
perpetuity. The ocmnittee believes that schools hove the responsibility 
to lake certain that: (a) professional education is training for a real 
oco^tion at the end of the line, (b) that the general education content 
is sufficiently balanoed with occiqpation-specific skills, (c) that when, 
and if, students widi career advanoenent throug|h education ttwre is a 
relatively efficient pathway to follotf, and (d) there is a realistic 
balance bst^esn the role af^irations of professior« with the realities of 
day^^to-day irork. In fulfilling their responsibility to students, 
education decision oakers face a nadaer of dileonas. 

Haal Jobs Qiere are lunerous job titles under the tniarella of allied 
health. Not all of then need to have separate, fomal academic prograns. 
However, educators nist be sensitive to changing technology and disease 
pattems which nay warrant such reoent develofinents as genetic counselors 
and magnetic resonance imaging (MRI) technicians. 

Ihe Southern Regional BSucation Board has reconnended— and the 
connittee eonsss— 'that academic instituticra oontceplating the 
develcpnent of new allied health qscialties ask thonselves three 
pcactioe-related questions: 



o An then any legal or prof dsaiGnal restrictions en the nev 
pgactiticwCT that %rill tmd to inhibit utilization of 
graft lates? 

o Is the nm qpecial^ sufficiently different frcn existing 
specialties to justify the dsvelopsmt of a nsiNT educational 

o Miat degree ot liability does the siqpervisor of the new 
pcactitionarB assuoe? (Southern Regional Education Board, 

Miv^^^^jf VSeculty in professional or technically oriented 
piuyiaius in hig^w: education face a oontiniing struggle to reconcile the 
denands of itnfiiemlft fbr scholarsh^ and general education with the 
pressures frcn oployft. ; and aocxediting bodies to prepare students for 
technologically denanding jdss. Ihe argument on the side of liheral 
eduoation is that the educational program oug(ht to be presiding 
preparation for life, not just for a specific job. Graduates auet be 
prepared to respond to the iMvitable changes in socfety. 

Iteiy eduoaturs feel the pressure exerted by eni>loyerB (especially 
Mployers in fields that require familiarity with instxunentation) to get 
graduates %lio do not need extensive orientation. Even at the ocsnunity 
oollegie level, lAdch has had a strong tradition of job orientation, there 
is conoem about the appropriate mix of general education and 
technical/clinical ooureework. In one small survey, 25 allied health 
oonnunity college deans reported proportions of gmeral education to 
technical/clinical coureework credits ranging from 8 percent to 35 
r^'roent, %dth an average of 22 percent (Kemdnski, 1987) « In the name of 
4 ^pcnsiveness to a changing society, general education courses ccopete 
vitji pressures to inoarporate qeriatrics, ocnputer applications, 
aulti-ocniietency, and clinical eoqc^rienoe in alternative sites of care. 

Ihe oomnittee is syiqpathetic to the dilemnas fticed by curricultsn 
planners. But it is also oonc e me d that students receive the education 
foundation on Jdtddti they can build a career if they so desire. Ihis 
entails developing the cepacity and interest in lifelong learning. 
mrthenDore, if current skills becceoe obedete, practitioners have a base 
vpon irihich they can develop an alternative career. 

liltl^latlgn Elizabeth King, allied health dean at Eastern Michigan 
Ikiiversity, describrii hypothetical students to illustrate the personal 
dimensions of the problems of articulation, the process by the 
ifward educational transition among acadenic ptugiams is achieved (King, 

- 40 

One staident, having wosiced Mven yun as a oartlf led oaxqpational 
ttarapy anistant "with a lov* of the ptofeeeion and a oanscicus decisicn 
to build vpon her currant skills," is oonfUsed and disillusioned %dhen 
denied tiie onpcartunity to transfer her profeBsicnally related ocureeuock 
tcMod an oaofational therapy degree. Meanuhile, another student with an 
associate degree In gv^al studies, hearing about the good job pcoqpects 
for ooaqpatienal therapists but having litUe knowledge about what 
oooqpational ttienpists do, is advised by tiie eenior college tihat all his 
ocuraes will transfer and he can oooplste the degree in two years. 

li\ general, states havs strongly proDOtel the conoept of nilt^e 
entry ivnd eodt points in health careers to aininize the loss of student 
tine In acving tttaafi oertifioate, associate and baccalaureate prograns. 
Without strong aandates or inaentives, however, such piuAMM* have 
difficulty overooD^ng sane inherent barriers. King iHenmeen a naher of 
these: currioular ptdblaBS occur in judging the oceijatibility of ^\<kf^^f 
and clinical content, and therefore it is difficult to assess advanced 
placenent. Ohere is at tines a lack of oonnunicaticn between acadanic 
affairs and artnlsslons ott ioes to work cut problens regarding credit 
transfer policies. Finally, and perhaps Bost iaportant, faculty 
professional biases, in King's view "the nost insidious barrier** czeate an 
cnvironeent of "undiscussable tension". Ohese biases laLiel ocnnunity 
college students as "technically" trained and laddng in problaoft-solving 

Ihe ccaanittee l euMaue iiJs that alternate n athwavs to entrv-lcvel 
practice be enocuracwd %*ien feasible. State hi caier education ooordlnatlncr 
authorities and leaislatlve oaBlnit^1>fff ttf^M I nsist on fladbilitv in 
educational mnhiHtv betawen oammitv oolla^ and bata ealaureate 
p i Tx iraBa; . 

BS2lfi_figcgQlBDBe a oontinuing tension exists between health care 
administratoTQ and professional qaupa over the tendency of a field to 
assume more scphisticated or broader responsibilities and the perception 
of cnployers (or payers) as to the legitimate and valued fkmctions that 
need to be perfarmed for patients. 

Kofessional associations and piugiam faculty see their job as 
defining and shaping their discipline. Ohis pxjoess gets reflected in 
curriculum content and is reinforced by accreditation. 

KseQth care adninistrators beoonr ounu em ed when they believe the 
curriculUD is being used as a precursor to o^aanding the legzd scope of 
practice and reiahurssnient %iithout recognition of what is possible or 
likely in practice, or when they believe that an oco^ation is at the same 
time abandianing "hands-cn" patient care for "professictial" 
xeqponsibilities not valued high.', tf those outside th.* field. 



- 41 - 

Car* mot be taken, however, to assure that students do lut get 
idxed in tteae oantxoversies. mtimtitely, these Issues aze resolved 
by the aarket, as represented by oonsuner tastes and cq;>layer hiring 
practices, or by public policy as repraemted by reiidsuKsenent or 
lioansure decisions. HcMever, vhile ttaMe issues are in the prooess 
of being resolved the canoftittee believes that educators have the 
zeqponsibility for assuring that students have realistic coqiectations 
of what ^ world of wock is today, neat only Oiat it ni^ be in the 

1^ >^ma«»y»nt BetMBen Baiv^»<m unri fiftriHoaa Alcng vith the 
c^hxation program's reeponsibility to students is a reaponsibility to 
acTiaty in assuring that the heelth care systen has the hunan 
xeeources it needs to fimcticn »«11. mdeed the rationale for the 
oonnittae'a atqpport of pdalic intarvention in allied health supply 
issues is based on its beli ef that the link between service and 
aduoation needs to be strengthened* 

Ih dstarmining their prograa offerings, allied health aduoators 
are cauticned by state hic^ education leaders and health care 
adtadnistratocs to avoid overtraining in both curriculum content, 
lengtt, and level of preparation* On the other side are the 
professions vho caution against too little training and who strive to 
alevate education standards through licensure, program accreditation, 
and raiafaurseetBnt standards* 

Ttm ocnaittee has heard arguments by the first graqp that 
raising educational qualifications is not only expensive to the 
student but to the education aystoo and the health care systen as 
%Nkll, both of vhich are attenpting to control costs* Furthermore, 
proponents of this viaw contend that "education creeps axacerbates 
shortages by lengthening the tine recfaired to pnpare an individual 
for liork* Ihey also contend that there is little evidence to suggest 
that current levels of education are creating care proialens* 

Counter argunients are most often based on the csqpanding 
knowledge base that practitioners need to master, and the limited 
time vmiUble in the curriculimi* New sites of care, such as in the 
hone or in independent office practioer require a level of judcpnent 
that can only be achieved vith increased education* Ohoae ooncemed 
with an adequate supply of practitioners point to the hi^^ labor 
force participation rates and longer tenure of thoee %&» have already 
attained ttoe higher credential* 

Ihis oosnittee encountered a nuDober of ttmam types of 
oontrovarsias among the allied health fields* For eoonple: 

o physical therapists atttapting to estahliA the aaster 
degree as the ^ntry-level standard 



- 42 

o role dallmation detotas oncng baooalaureate nedical 

tadnologists and txryar nadical laboratacy tecnnicians 

o pnposals to Xinlt tha aduoaticnal xcubes to crtry-level 

o wwant of zwpizatory therapy to a baooalaureate 
antiy^level standard. 

Ohe oaao fdr pctnoting a ain^e qptined level of education is an 
aoonadinoly difficalt ore to sake on e nrlrlo w l gcamSB. Wian an institute 
of MKlicuta conaittee aaqplond tt» oontxcwerqr over tha three eAJoatlonal 
trades leading to tha xegistered nurse oxedantial (associate da^pae, 
disioaa, and baacalauLeate) , it was m^e to find convincing evidmce on 
the perftcnnae difference of gradaatas (institute of Mediclna, 1983) . 

rtm oonnittae mithar endocaes nor zefixtes tiM position of parties on 
either side of these ddaatee. m view of the lack of objective «Bi)irical 
evidence and tha linitad scope of the peasant study, the oomnittee oould 
not justify offering oondusioM that nic^it influence the outocne of these 
acntzoversies. Ihe ocnaittee does suggest, however, that those aaklng 
dacisiora aske sure that changixig eodsting practice «dll not limit si^y 
anl not sake care eafloas s ively oosay. 

Ron the oonaittee's psrapective the only sensible re^xnee to the 
BDvim targets at healtii caxe aysten change and the lack of oertainty 
dsout hotf to Batch education to future naeda is a continuing feed-bade 
loop between education and practice. Graduate foUcw^ studies that 
incorporate «i|>loyer paaxsptions are the aost dizect aaaaires of hew %«11 
tha curriculvn is pnparing studants. Ihe aim of these studies hcuever, 
nesd not solely be to tailor education to anployar perceptions of need. 
Rither it ^xuld be the start of a dialogue. If students are not qpplyuig 
their education esqperienoes fUUy, the problon aay at tines zest %fith the 
vork envizonnent. A dialogue oould potentially lead to a mitually 
beneficial set cf activities involving aore participation fkem health care 
unagers in curriculm design and greater involvement of educators in 
health services xueearch vith practical a(i>lioation to clinical settings. 

vsrixxm Bcdels are available for institutionalizing such 
interactiora. Ih soma rlucation prograns, allied health education and 
aervices are jointly administered by the sane cocporate entity. An 
eaoBDle is Rvh Ikiiversity in Chicago vhsre education and ssrvioes are 
mified. liwre this is no:: feasible, inkjstzy advisory boards oobboi to 
now coonunity cbUeges can be utilized, faculty practice i^ans or 
dinical af filiatiora aoy also serve as a starting point to stisulate 



- 43 - 

In those fiel<te \tm% instninsntatlon pli^ a najor zde in job 
ftincticning, indtistxy/faoulty collaboration prcvides a largely 
m±appBd xwouroa. HBunufacturers ultimately have a etake in human 
reaoutois, because investnent in technological inncivatiGns hy health 
ficilitiee My be seriously haaperad if there is a lack of acSeqoately 
prqperad perscmal. HEunufecturtrs should ocnsider collaborating with 
edi»tion institutions in cxeative vays— ^the use of equ^nent, 
fteulty-lndkistry issamili pcpjects, rt»rt-teni cqploynent 
CHXirtunities—cis a eeans of ensuring a tesBon nsouroe infkastxucture 
to assist technology transfer. 

8cBB stinilus, however, is neoessaxy to amtoaae the inertia of 
dealing vith theee toug^ issuss of oollaboration. The ocnnittee eees 
a role bo^ fior states and private foundations in prcviding that 

shcMld saopQrt tmiveraitv^-haaed caanters for allii 
poUgy to pfngi/4A> m ffHl-iniil tmm of raaearchgra and 

in tht rtttTBtIm 

Private f cundattcna 

states have a sajoor rde in allied health education by virtue of 
their sivport of public colleges and univeraities. In addi«don to 
this influanoe, iim^ are freqjently drawn into debatiBS cnbt licensura 
issues involving changing scopes of practioa and licensing of new 
ocd^ations (Theee regulatory issjes an dlsnissed in iliapter 7) • 

Private foundations could have a ujcr impact on the future of 
allied health education and practice by creating cantera of 
eoccallence in a few anartflmlc institutions. Many advantages mi^ be 
gained by coalescing a coce iwemili faculty «ho alec provide 
services. Iheee autually xe^iforcing activities would enhance the 
quality of leeiinn h and patient cara. FLrthernore, these cantera 
wdtftt than serve as a resource to other allied health education 
piujiauM regionally or nationally. 

^ ocamittee believes that the interest oC states legislatures 
and private foundations in the andeavora \m dracribe %dll be kindled 
end sustained only by a ccntinuing federal preeare in the o onueiw 
of allied health education and practioa. Tear this reasons, the 
ocBBiittee aakes the f ollawing reocnnandation about the federal 

i><ntai4n mn oPMnlgaticgwil fhnal 

point on BlJAmA >^lth paracnnel 
in this report, to 

in thapter 21 and to facilitate O MtM^jat lm teS&afiD, 

and the ftdBnl TTtvwtttt 

- 44 - 

Allied Health Bducaticn Advisory Oonnittae. 1980. Guiding Gdnoepts for 
the '80s. C8 Stud/ Beqper 29. Taoas: Cooiidinating Boaard, Itexas ODllege 
and tftiiwEBity Systsn. 

Anericeui Om r w t i cn al Iharapy Association. 1987. Meniaer Data Survey. 
Mucin Report No. 1. BDdkvills, MD. 

American Rorsical Ohazapy ABsociation. 1987. Active MeniDanhip Profile 
Study. Alexandria, VA; Anericeui ftaysioal Ttma^ Associatin. 

Anerican Rvsical Ibeaapy Association. 1985. Hie Plan to AdSress the 
fiojlty ShcKtaqa in RvBiced aherapy Eduoation. Pinal Report of the 
Tulc Focoe on Iteulty Shoctage in Riysical Theofv Education. 

Area Health Education centers Kogram (AHBC) . 1987. Health issues Mbrking 
Crop on Health Rnofessions: nrognon mvantory. Rxikyille, MJ. Health 
Reeouroes and Services Administration. (Fttsruary) 

Astin, A.W. 1985. Minarlties in American Hic(her Education. Joeey-Bass. 
San Francisco, California. 

Bisoonti, A. 1981. National and State Crofiles of Collegiate AUied Health 
Education. 1979-80. American Society of Allied Health Profession. 
Oontrct Nb, HRA 232-79-0095. 

BLeich, N. 1987. Strengthening Sqpfxxt NetuoclcB for Minorities in Health 
Science Careers: A National Synposium. New York. Macy Fbun3ation 

Bleich, N. 1986. Bihancing Oppcfomities in Science, Mathematics, and 
Health precessions: An invitational Conference. Reno, N&vada: Macy 
Foundation (JUly). ' 

Booker, N. 1987. Bac3cground paper prepared for the lOi Study of the 
Role of AUied Health FerBomel. 

Broetki, D. «t al. 1985. mcxeasing Research Rnductivity in ttiiversity^ 
based Oollegas of AUied health. Journal of AUied Health. Vbl. 14, 
No. 1 (February) :160-162. 

Brcwn, R. 1987. Background p^?sr prepared for IGM OGnmittee to Stidv 
Role of AUied Health BsTBonnel. 

caucpcntar, H. 1982. isisadvantaged in the Health Resouroas AAni].i9Q»tion's 
Allied Health Training Rograns: A Historical Iteviev. Health 
Reeouroes Administration (JUne) urptftaiehed. 

Bie Circle Inc. 1987. Revitalizing Riamacy and Allied Health Itofessicns 



- 45 - 

Bdbcstlon far Minaritles and the Disadvantaged. Health RescRzroes and 
Suzvioas AAniniatraticn. 

Cbllaga of iMaalth Deans. 1987. OfubliidMd survey data. 

OGBBittae on Allisd Health Bduoation and Aocxeditaticn. 1987a. Vrogr^ 
mrm^bsgrs' Penpactlves Rigaxding CMIEA Aocxedltad Allied Health 
Bducatlon. Sianaxy of a 1987 survey. In Vr&BB. 

Ooenittae on Alli«l Health Bkicaticn and AocxeditaUcn (CAHEA) . 1987b. 
VOluntazy Vtoyam NithdraMals from aHEA aocxeditaticn, 1983-87. 
Qiioago: imerican Medixaal Asaociatlcn. 

Oonnittae on Allisd Health ttboation and Acxa?editation (aoSA) . 1987c. 
Allied Health BAacation Directccyr 1987, Chicago. Jtanerican Medical 

Ooqperatiw institutic>ial nBSoairh mogran. 1987. 1987 Fteshman Suxve^ 
Raport. TJhiversity of California. Los Angeles. 

Gcwcy, P. and Burke, J. 1987. Research and ^ Mission of Schools of 
Allied Health. Journal of Allied Health. Vol. 16 (February): 1-5. 

Education Ocnnissicn of the States. 1987. ABUPiBrnnftnt- and CXitocnes Measure- 
aient — A View Frm the States: Hi9(hli^(hts of a Nev ECS Survey and 
IhdiviAials State Fzofilss. FS-87-1. March. 

EUdis, C. M. 1983. Aocreditoticn: Oiapelling the l^ths. Journal of 
Allied Health. Novcntari 249-261. 

Fitzgerald, L. P. , and j. 0. Crites. 1980. Toward a careo: Itaychology of 
Women: Itat Do He Rim/? Miat Do We Need To Km/? Journal of Gbunseling 
Peyctelogy, 27:44-62. 

Flack, H. 1982. Minorities in Allied Health Edication. Offices of Health 
Hauauiaea G|pcirtuiiity. Rodcville, Md. Health Itosouiooe Adninistration 

Garrison, H. and Brot'ii p. 1985. Minority Aooess to Research careers: An 
Evaluation of the Honors IMergraduate Raeaarch Tkidning Program. 
Ccnmitta. on National Kaeds for Bionedinal and Behavioral Personnel, 
ftafihington, D.C. : National Aoadeny Vnea. 

Gonzales, C. 1987. Minority Bicnedical RMmmTh Program. Bethesda, Md.: 
National institutes of Health. Division of Research Resources (March) . 

Health nesauicee and Services Jteteinistration (HRSA) . 1987. Refxirt to 
congress on Nursing and Othsr Health nof essions Educational :%ograns 
RilBiJursed Under KBdicare. Roc9cvill«, Ml.: Health nosouroee and 
Sendoes AADinistnrtlon (Decenber) . 

Health nesouroes and Services Mni stration. 1986. Rqnrt to the 

Ikssidait and congress on the Status of Health Personnel in the united 

- 46 - 

Haaltii Ikofwsicns Re|xart. 1988. Social Work School's BiroUment 

UrcxsemB, But TrmA not Uiiversed. Miitalcer NeMBlettezs, Inc. Nm 
JttSiy. Vbl. 17, Nd. 2 (Janaaxy 29):2-5 

Health naaauirjM and Saxvlow Mh&inistzatiGn. 1984. An Ih-'OBpth 

Examinatlcn of tha 1980 Dicsrnlal Omnmrn Bnploynent Data for Haalth 
OaqpatiflM: Oafxtahaniiva Rqpoct* Mbllc Haalth Saxvica. U.S. 
Dyn ai t—i t of Haalth and Buann Servioaa. JUly. ODMf Rafort No. 16--84. 
Nashingfton, D.C. : U.S. QcNmcnoBg^ Stinting Qffioe. 

Hadricic, H. 1985. DiBOontinuation of Allied Haalth Schools and Prograns. 
Is maxa a Battaxn. Jouxnal of Alliad Haalth. Vol 14, No. 1 

Haxr, E. L., and S. Ckaner. 1984. Caxaar G»ic1anr» and Oounaaling Tiuxup 
tha Idfa Spm. Boatcn: Littla-Brawn and Qo. 

HolOGDi), J. D., D. W. Evana, W. P. Bucknar, mrA L. D. Bandar. 1987. 
A Longitodinal Evaluation of Graduata Rxqr a m s in Alliad Haalth 
Bdbcation and Jkteinistxation. Jouxnal of Alliad Haalth (Mhy) :119-133. 

Holland, W. 1987. Personal OGraunioation. Division of Disadvantaged 
Assistance. Health nooaui'coa and Sexvioes Administxaticn. 

mstituta of Madicine. 1983. Mixsing at:d NUxsing Education: Rthlic 
Felicias and Frivatm Acticns. Nashingjton, D.C. : National Aoadeny 

RLsason mstituta. 1987. florkforce 2000: Noxk and Woxtars for the 21st 
Oentury. Indiiuiapolis: Hudson Institute (JUne) . 

KentucKy Oouncil on Hi^^ier Education. 1982. Ibsk Faroe. Kentud^ Allied 
Health ftpjact Final Report. SeptaniDer. 

Xing, E. 1985. Axticulatlon of Allied Health Education. Revicv of AUied 
Healtt Bdi ration: 5. mA. HBoixtxg, J. Lexington, Kentudty: Ukiiviixsity 
Rrass of Kentucky. 

la Jolla MBUiagaent Oocpoxation. 1984. An ArmnraBiiiffrit of Rrepaxatoxy 
Activities for the Health Chxeexs Opportunity Rnogram: Final Report. 
Health UDOouroM and Sexvioes Administxation (Oontxact No. 

Lent, R., S. Brawn, and K. Laxk. 1986. Oonparison of Ihxee Ihearetically 
Oexived Variables in ftedicting career and Acadonic Behavior: 
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of Od meling B^ychblogy, Vol. 34, No. 3:293-298. 

Iswln and Aaeociataa. 1987. Hoepital Dadaion-MEddng About Offering Health 
Itof essions Qinioal Miration qpportunities and the Effects of 
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- 47 - 

Of Ihi Qoelity of Uboratory staff en the Aaamcy of Zaboratary 
RMUlts. Joumal of the Aoaerican MadiceO. Aseoaiatlcn. Vol. 258, No. 3 
(July 17):361-363. 

HBdcra, P. 1979. Ctaatlng Nov Alliad Health Itograss: Gomidaratlora and 
Oanstxaints. Atlanta: Southain Rsgional Edacation Boazd. 

Mndax, Ihc. 1987. An Aanfinniiiint of Stats Scppcat for Health Ftofeesicns 
Bduoation RragzaoB: Final Rqpoct. Haalth Itooouixiofl and Sezvioes 
Atkdnistzatioi (JUna). 

M a t h em it dca Policy RBoeazch, mc. 1987. Draft Final Report cn Dq)lara- 
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Alliad Health Pkofaaaiona, 30, 1987. 

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Miaaouri Ooccdinating Boazd for Higher Bdhication. 1986. IteccnniendationB 
to the OOmittee on Acedenic Affairs regarding "state-Level Review of 
fidjating Itagraons Haalth Sciences Education." April. 

National nmrnissi on on Allied Haalth Education. 1980. Ihe Future of Allied 
Health Education: New Alliances for the 1980s. San Francisco: 
JcsMy-Baas Inc. 

Mev York State Education Departanent, Bureau of Hic^ and Professional 
Education Testing. 1985. Program Guidelines. New York State Education 

Perrin K. L. 1987. Renazte at the Synposium on the Future of Allied Health 
Education. Susquehanna university, tasisylvania (April) . 

Petezadcrf, R. G. 1987. A Report on tiie EstabliiAinent. Joumal of Medical 
Education. Vol. 621 (Felmiary): 126-132. 

Resseller, 8. 1987. Rxsonal Cdmunication. Anerioan Ooofational Iherapy 

Social and Scientific ^ystenB, Jinc, 1987. Strengthening Support NStuorlcB 
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of Health and lianan Services ( Janiazy) . 

Southern Regional Bduoation Boazd. 1980. Planning and Designing 
AUiad Haalth fiduoaticn for Pkognnn Review. 

U.S. Dqpaztaent of Health and naan Services. 1987. Report to Oongzess. 

- 48 - 

Draft on Nursing and Othar Health Rofeasicns Educational ftograns 
Raiafcunad IMar Nidioara. Buraau of Haalth FEofassiora. Health 
ard SaEvioM J^tinintration. 

U.S. D niail—iL of Haalth and Hnan Sarvicaa. 1985. R^xirt to the Secze- 
tary'B tumk Tckxm on "Blade and Minority Health." August, ftaahingtcn, 
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U.S. Dqpartamt of Health, Bkacation, and Nelftoe. 1979. r R^xa± on 
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Mhdniatration. Novwber 26. Nashington, D.C. : U.S. Govexnnent 
Rrintixig Office. 


CHAFiro 6 


Mmy of t^ ) ttaoM that zun Mparately throug^h this report ocne 
together ytm w begin to vim allied heslU; wrkarB ftoD the perspective 
of health care eaployera. If the supply of practitlcners in an allied 
health field declines because fewer students choose tiie career or because 
schools dose, health oars odhninistratocs %te sploy allied health 
persGmel are ascng the first to experience the chmge. if licensure laws 
change or a new technology is introduced, wployers are among the first to 
raqpond to the change. If a glut of wriotts in an allied health field 
exists in a locality, eniaoysrs %iill notice it in the raeponee to 
vacancies they advwtise. 

Bqployers ere tdt wrely ueers of a given supply of allied health 
personnel, however; the/ are aleo active participants in the forces that 
determine the supply of worters. In other i^ords, the quantity donanded 
and the quantity sin^ied are not independent. Wage and salary rates, and 
working oonditiions affect the simply of vorkers. Ihe supply of workers in 
turn effects the %«ges and salaries, and working conditions that are 
offered. But ea^^oyers setting wage and salary levels have to balance 
aany considerations other than the amount cf pay needed to attract the 
ntfiLnA naber of workers. Ihey laast consider the paymen t they can get 
for aervioes and tiie bottcn-line ispact of personnel oqponooo, the 
regulatory requirements that oonstrain saipcwer deployment, and the skills 
and knowledge demanded ty the techndogiee used. 

In the past, OQst*4)a8ed raisbursanent, the absence of conpetiticn, 
and a generally adequate supply of allied health personnel allowed 
administrators to make the salary adjustments needed to maintain their 
desired staffing levels. Ihey have been able to aoccqplish this without 
appreciably changing staffing or service levels or the deployment of 
staff. But changes in the health oare system and in allied health labor 
markets may force administrators to rethjidc staffing practices. Ihere 
will be increasing con()etition for technically^oriented workers who have 
more options ttian non-tedmical workers in where they may work. Also, 
administratoni will have strong eooncnic incentives to control personnel 
oosts in order to ooqpete on prioe yet remain financially viable. 

Iheee changes constitute a new environnent with which administrators 
have little eoqperienoe. Although eone administrators have had to face 
periodic ahortages of nurses, only recently have they faced personnel 
ehortagae and the new eooncnic environasnt simultaneously. Ihere is no 
history to indicate how eBployers will ad2^ to difficulties in hiring and 

- 2 - 

Iht oonnittM idontifled ■one allied health ptofessicns in vhich 
ihortagaB are liJoaly to occur if changes in the labor aarioBt fall to take 
plaoft. This chapter focuses on forastalling ihartages; it oqphasizes the 
i^portanoe of plaining tat tte ftituxe. Ifariait aechaniflns will foroe 
adjustBBnts that will eventually rtenrawse stuseus in the allied health 
labor aarhit. But aaitats adjust slovly. For exaiple, there is a 
considerable tiae lag between edjoational institutions recognizing and 
zeeponding to Incxeased student interest in an allied health field and an 
incraaee in the naiaer of graduates. Boq^Xayers have mnerous reaacrs to 
act early to forestall tfiortagas. Fbr instaroe, acute ihartagres of 
tparioBTB in an allied health field say oauee ealaries to rise tfiazply, some 
services to dose, or the initiation of a nav rmerteil service to be 
postponed. Moce subtly, the quality of care say be ercjdad if, over 
extended periods of tiae, existing aiployees aust struggle to uintain 
aervices. Iheee and other serious service dislocatione could be reduced 
if administratars reapond to early aazlOBt signals. 

In this chapter «e will focus oainly on vhat peracmel 
a dm i n istratars, oorpar at e hanan zesouroe adndnistratarB, and departasnt 
heads in all types of health care facilities—ho^itals, nursing hcnes, 
freestanding facilities— ni^ consider doing to help relieve or prevent 
■arpoMBT rixjrtages. Ihe chqpter will discuss two ^es of activities that 
can prodooe gains in flaipower simply. One is to nake cnployiimt anre 
attractive. Ihe other is to use the available wockforoe anre 
effectively. None of the activities rtlsnisfwl are nev; they have been 
tritd in fields other than allied health. Ihere is a need for further 
investigation to ascertain which activities are best suited to resolve 
problens with the allied health labor fbroe, taking into account the 
different characteristics oL the wcckforoe in each field. 

Ohere are other ways that health care providers can initiate 
activities to lessen their probleos. For instance, Texas ho^itals have 
reaponded to shortages by using the state hospital association to nount an 
elaborate caopaigki to recruit hic^ schocl graduates into health careers 
(Texas Health careers, 1987) . Other atedianisnB, such eis offering 
vacationing hi^ school students jobs in health care facilities, are also 
used to infom and encourage students to select health care careers. 

ihroughout the chapter terns such as human resource administrators 
and facility adninistrators are used. Ihese terns are purposefully 
vague. Health care organizations todir^ often have a personnel function to 
facilitate the details of personnel nanagement, departmental 
administratcre who naloe decisions about the deployment of staff in their 
realm of raaponsibility, and vpper-level hman reeouroe administrators who 
deal with facility^dde labor force issues. Siis fkagnentaticn will make 
it dif f ioilt to develop and iaplement czeative staffing arrangements that 
are likely to be part of the solution to allied health staffing probleDS. 


Strstagies tear Dic>loyer« to Bihanos ttm Supply 
of AUiad Health FKactitionen 

Glvwi tbB dininiAing six* of ths co U a g * age papulation, students' 
pccpamlty to chooaa caraars outcide of haalth oara, and the decreasing 
availdaility of alliad health poDogxans on the one hand, and the aging of 
the pcfulation, iHaannn pattazra, and tachnologiaal advanoes in health 
oarrt on the other, there will be an iiisalanoe betsuean Kfply and demand 
far mjm groqps of al iad health uadaen uilaM 6»re is a ct»ncp on one 
or both sidM of the eqaation. HcMBwr, gmralixations of this sort do 
not nbly to all allied health fields or to aU locations. DooDand rmd 
sivply vcsy txn place to {Oace, and vith varying circunstanaas. 
Ihdividaal facilltias, areas, or zegions will in scne cases «qperienoe an 
adaqoste or even amiana supply of personnel in fields where a national 
ahortage Is prediebed, and the balance between tupfiy and donand will 
dlffir nang the fields. This is readily tppm± today as facility 
aAninistratocs struggle to hix« fi^slcal thtrapists in locations %tere, 
fbr flBOBipls, veipixatocy therapists are plentiful. 

Ttm a^actatien is that in nan/ parts of the nation and for nany 
aoDloyen of allied health practltionare the labor sarlQet wiU be tic^. 
IWo ^pes of actlom are available to relieve the pressures of peLvonnel 
ahortages: one is to increese the supply of worloerB, the other is to use 
ovailebla warioers BoirB productively and effectively. 

lb ixvaease the sifply of wori^v, toployecs can int erve ne to make 
education acre aLnassible, and oan sake mploynent mare attractive. 
Studmts than be sore likely to select allied health oaraers. People 
who have le.<^ the w ori cf orce to pur:ue other inteKSsts— children, new 
oareeni, or leisure— ny return. »brkers say choose to ranain in the 
wcckforoe longer, or mali^ n a career longer, increasing nvply by 
encouraging greater naiiers of students to enter the allied health fields 
is a stxatagy that dapends both on eapiiayere naklng allied health 
anploynant wra attractive and on educaJxn ^tutions reeponding to 
inczeased dnand by potential studaits. 

Ttm other strata for coping with aiiortaga, using wockers ncire 
•inductively or effectively, / eeMToe reduces donand for allied health 
pere&YiBl at & given level of output. But there are limits to the 
productivity i^axweeents that oan be achieved. Iheee linits can result 
fxtn regulatory ooratzaints, the aikills of individuals, technological 
oonstraints, as well as the nature of the work. Ihe challenge for 
aAoinlstrators in today's oonpetltlve health care anvironoent 5s to try to 
eraute that productivity i^sovMaants are pushed tciMrd the linits. 

Mertakijng one or both of these strategies wou71 require nerious 
lecoradderatlon of the role of tanan reecurce Mnaganent. For oary 
facing adninistratare it would aaan giving hnan xeeouroe sanagsnent a 
hi^MT priority than in the past. However, Au:h investments, or efforts, 
would be repaid if the service dislocations that oould remit fton tl^ 
wiTouer oaxkets were avoided. Moreover, private aector anployers Bust 

ttfoi tht initiatiw in atencln? the Mvply of aUi«d health perBcrr ^. 
IhB pift>lic policy optdons, such as prayianw of grants or sdMlaxahips, 
oamot on thsir om solv« ■arpowaar prcblans. Kaking aducaticn iiwo^eraive 
and vaadily availabls aigfit suooatd in attracting acne people into allied 
health fields, taut uiless then are •^good" jobs offering coqpetitive wages 
the nate of people attracted will tae inadequate, and those that choose 
an allied health oooqpation will not stay in it long. 


a perfec±ly ocaiNtitive aarkBt, an iidaalanoa between supply and 
dsnand would cause prioe to change until n^ply and dnnd were in 
eqiLiilibriuB. Ttua, if a ahca±flai of allied health persomel were to 
occur wage rates toild be aoqactad to lioa, dnand to fidl, and the supply 
of peraomal would incxeasa to Batch daand. This series of xeacticne is 
likely to occur in the allied health peraomal aarket. But muket fbroes 
do not always work fkealy, and there can be delays beftee egoilibriaB is 
re n stwhUrft e d . If danand increaaas at a greater rate than siqpply, wages 
Bay rise but there will be a lag before n^ply catches vp with dtaiand. 
Also, wga rates Bay be slow to respond to sifply shortages if «B|>lcyerB 
are vnwiUing or unable to raise wages. An ao^laraition offered for the 
slew adjustaent of nureas' oonpenaation is that large health care 
pEovidere, such as hospitals, have oftsn been one of just a few «i(>loyerB 
of allied health practitioner* in a locality, an) realizing that these 
practitioners have few alternative places at which to work, «Bi>loyerB have 
been dale to krep wage rates down (Aiken, 1987). HoMever, in nny local 
Barkets ccBfjetition fbr allied health practitioners hu been increasing 
with a proliferation of worksites—freestanding units of naeraus types, 
9 n»f\m m intapandsnt practice options, etc. Slew wage adjustment can be 
•oqpected if enployars do not recognize that wage oon()etition is taking 
place, ihere are also Baiy reasons for being relixtant to adjust wages. 

Sonstiaes «i|>loyerB recognize that confietition for wockars is 
occurring but are unable to oonpeto with salaries offered by oOier 
organizatione. Sone ^pes of aaployers for whcm this is likely to be true 
are disouesed at the end of this chapter. Daring the couree of the study, 
the oonmittee often heard of ^liad health pKactitioners leaving 
traditional aaployBBnt settings to establish indspenknt practices or to 
w»£ic for «i|>loyers such as health spas, food Banufacturers, anl 
biotechnolcgy fizBS, whsre substantially hig^ salaries are being 
offered. Ike ocnnittee also heard that the traditional service ethic that 
attracted individuals to valativialy low^ipiying health oar« jcte is being 

oded. Opportunities in alternative {Oaoes ol week or hi^wr paying 
Ofaireers are felt to overwhela the tradi^onal aervice satisfaction. 

Bi|>loyen ,* reliictanoa to reapcnd to indicatiora of shortage by 
raising salaries stans no. only from the asqpense of paying hig^r wages to 
tte acaroe group, but also bscause the ocepsnsation of aary types aC 
workers in a hospital are ast in relation to each other. An incTBaae for 
one type is likely to be quickly foUowed by incraases for other types. 

- 5 - 

Such fidlmw of ttm naiOBt ara not imiqua to health oara pcwiaecB. Ihe 
WOl Stzwt Journal (Mitchall, 1987) , iwting a Mrious shortage of 
blue-collar aldlled cxaftsnan, marked. 

Surprisingly, ttm lidbor aarkst has qperked only aodeet 
vega gaine eo far. Althouglh deq)eFate fdr oertain k0/ 
ekille, eoaei mBglogmn vould rather lisp along without a 
full wtkfdroe than ndee \mqn hi^ enough to attract 
needed %»rkere • • • aany oaqpanies have choeen to ignora 
iesuBs of «vply and dsnand fbr fear that hig^ labor 
ooste ifill BBlQa it wre difficult to ooB|)ete. 

Jn health care a eiailar attitude prevailed Itm Vm York Times 
(UchiteUe, 1987) cites Jerone Grossnan, chaiman of the Heur Biglard 
Medical Ostter, itare 200 of 2,800 jobs ere vacant, as saying ""Qie 
asounte we oen charge patients are cappoA and so • . . ym are focoed to 
aeks trade-offs." Moreover, there ere scmetisee ^tsmatives to pay 
increaees. Itr exaiflpkle, i^hm Uboratory technicians are in ^hact supfly 
dMBdsts and individuals trained in other relevant disciplines can be 
substituted. If there are alternative sources of sanpower, such as 
lower- levsl practitiomrs or individuals vith other training, 
substitution aey be a prefereddle to raising pay. fbr exacple, in ere 
locality lAwre there is an c^ersupply of dentists end a ahortage of 
bygieniste, an HO uees dentists to perfam ttm bygienists' tasks. In 
some allied health fields ffceedon to eubstituts is ooratrained by 

Altsmativsly, aervioes can enwptimpB be nazginally curtailed and 
in dttmr oea allied health cnployees are adoad to vork overtime and 
aaasuras are taken to increaee output. 

Other %iays of attracting per so nn el tfarcug^h eooncBAic incentives 
vithout incxeasing vages or ealaries include peying bonuses for joining 
and string on staff, and offering continuing education end daycare 
subsidies. Ohis avoids an qpuard ahift in pay scales, so if utilization 
or ocavani^ declines the en|>loyers ere not left vith en exoes?lvely 
hiq^y paid staff and a i^entifUl siqpply« Evidently health care 
adainistratore, neoesearily ocamm e J with their arganization's bottom 
line, have atvailable an array of strategies that can be iaitlcmenbed 
before wage rates are inaneaeed, thus a lag in the reqpGnse of wages to 
a pttceived dtartage of pereomel is not uneoqpecbed. 

Although raising salaries has been ehoun to incxsaee the size of 
the nitsing woaicforce, other eccnonic factors also inflxience the 
decision to wor^. Family inocme is iaportant. As epouaes^ incones rise 
nurses tend to reduce tkmix working hcaurs or stop working altogether. 
And when nurses' ealaries becone hi^ enough, sona nurses reduce their 
hours of WDric. Oonvereely, in tiiae of hi^ uneB|>loynant inactive nurses 

- 6 - 

z«ftum to tte tPockfOKOB (Aikm, 1982) . ihese phmonana an lUoely to 
oaojoc in mam of the aUiad haalth f.ialds, particularly those that axe 
aainly onumnnfl of vemn and an sinilar to ruTBlng in m±xxtian, and 
pay l«v«ls. 

An imalysis of nuraes' oonpensatifin In relation to changes in the 
balance of donand and wpfiy of nurses notes that •rw»oi-^pa«f ^/gg^ 
inareases have lagged behind ahoortages. Ttwt sane analysis notes that 
%nge incxeases have r^»atedly simnneded in reducing shortages (AiJcen 
andMillinex, 1987; Biaihause, 1987). 

Pay differentials batMsen different educational Icrvels of the same 
occqpatlon also have the potential of increasing or decreasing the 
wpply of peraomel of a given level. For eooinple, «hen there was no 
dif ferenoe betMeen the earnings of baocalauraate nurses and associate 
degree lunees, students realized that the eoanGnic return to the 
taiio-year education vas higgler than to the four-year p rog ram and the 
nmber of associate degree graduates eventually the xuntec of 

baocalaurea«-ie graduates (Buerhaus, 1987) . 

levels affect the isi^y of allied health practitioners at each 
point at vhich an individual lakes a career decision. Although eooncnic 
oonsiderations are often not the sole or priaazy ooraideratlora, 
earninge potential is one of sany factors ooraidered by students 
selecting an t«Suoational program. Oxse starts on a career, 
satisfaccion %dth ourxent earning l€«vels and t^qiected increases in 
•amings wiU figure in decisions to ocntinie %icfridng, to leave the 
imricforoe, to pursue child oare, ielsure or other unpaid activities, or 
to change to another oocupLClon in whlcii the oapenBatlor. is better. 
Similarly, return to an ooaqpatlnn will be in part depenient on pay 
levels— eepecially «hen the cost of wori: inciuSes mjor eamenditures 
such as child care. 

Hew does allied health ccnpensatlon ocnpare with other 
«oajpatlons? First conpensatlon for allied health practitioners should 
Ite. understood in the ocnbext of vonen's earnings, because women doninate 
aany allied health fields. Ih 1986, wcnen earned on average 69.2 cents 
f^every dollar earned by aan (Hellor, 1987). Hareover, ooa«.ations in 
%«ilch icner represent the mjority of warkers tend to ratdc lower in 
tems of earnings than sale dr;;2xr^ted nmmatioro (Rytina, 1987) . The 
American Itiysical Iherapy AKLOciation (APIA) is one grop trying to 
address these problcnis. Iiey recently eocamlned factore oorrtributing to 
the dicp arlty in professional and •oonGnic status between men and wonen 
■eatoers m indicated by self-aiployinBnt, administrative resnomlbility. 
graduate degrees, and earnings. niU-time salaried female physical 
therapists had amual salaries that were only 85 perrsoit of those of 
full-time salaried men. Self-cDployed phyfiioal therapists are nore 
likely to be sen (62 percent) and they earn msre than self-enployed 



WGDBit. Tte aimal gross •azningB of these tcnm ws 71 peztsent of 
Mlf-«q4oy«d nan. The Am stud/ ooncludad that tha aasociatlon should 
mtploKm u micjadiss for cxmting oareer ladders, enoouiage wonen to 
oonndt thiwh>ee to carasrs and nintananoe of akills and consider 
■ocietal barrlars that liait Kcnens' aqpixations and 0[pcrtuniti«B 
(Raagan, 1986). 

Ttbim 6.1 arrays cmiwnBnticn data for aone allied health fields 
and Mleeted other oocqpations. Ihe data for allied health fields were 
dataijMd through a national survey of 33 hospitals, 16 aedical schools 
and 28 aedioal ontars. Ihese institutions vers <tes8n for their 
sinilarity in sixa to the University of Tbgbs Hedical Branch at 
Galveston, lihich has 11,000 bsds and 7,500 <Bi)loyee8. Thirteen of the 
institutiflns are in Texas, Arkansas, and Louisiana, lAich represents an 
avt'i smmling of tihat region. Ifaus the data pertain to larga 
instituticnB and haw a regional bias. Ohe oocqpaticnal catei,jric6 are 
oareftilly defined and claar, and although the Texas region is 
o> ve i s mu i l ed there are no other reasons to believe that the neuinwer 
aarksts of Urn institutions have ary fecial characteristics. On Tedale 
6.1 the starting rats refers to the rate nomially paid to fill a vacancy 
in the ocofiatian. Ihe mvliwini rate is the hi^^iest rate actually paid 
to oqployees in the oocKpetion (Uhiversity of Texas Medical Branch, 
1986) . Data for the other oocupations are fran a nation-wide salary 
survey of firos «rith at least 50 eB|>lcyeee. Each oocMpation was divided 
into levels with detailed job content descriptions for each level. For 
the non-ellied health fields tiie st&'.ting salary in Table 6.1 is for the 
lowest level, amrlwm is for the hiq^best level (Bureau of labor 
Statistics, 1986). 

Some of the occqpations selected for inclusion in Table 6.1 were 
choeen because the/ require investments in education coniiarable to the 
allied health fields. Others were chosen to show how con()ensation for a 
■aialler educ don^l investnent ocBfeirk^ with allied health fields, ihe 
table indie ites that starting salaries for allied health fields in ecee 
cases do not cxapare unfavorably with other occupations requiring 
similar educational investments or «hioh students might coneider as 
altetnative careers. For veanple, auditcre and accountants require 
bachelore degrees and have monthly starting salaries of $1,797 and 
$1,752, seiipectively; theee are similar to or a little below the 
starting salaries for p^ind and ooofKitianal therapists and medical 
record administrators «ho also require bachslor degrees, m ocncuter 
fields the starting sala rie s of systcns analysts exoeed the starting 
salaries for qpeech-language pathologists and audiologists for a 
master decp^ee is the entry level £eqiiir«Bent. Engineering techniciais, 
dascribad as "saniprofessional", and ormmfer cperatars re included in 
technical s4ppoirt operations and can be considered equivalent to madioal 
laborBtory and medical reoord technicians with associate dagrees. 


- 8 - 

TABLE 6.1: Monthly Salaxy Ganges of Selected Allied Health Ooatjations and 
Other Oaoupaticns, 1986 











Audio? ogist 

$ 1,872 

$ 2,334 





BOS Tacfaniclan 




nBalGBl LAD TBCtXnlClBn 




nBCUGU. HnCCCI JldlBinu^ XfttOT 




neaicai RBrara liKxinician 




nBuXGU. iBcnnQiogiR 


2; 174 











Pail f J- 1 nj J t ri ff^i J 1 SXSwi 




ranxBuiGn moxopy lULiJi MJxogxBC 




111 If i£ M ravMfc J UlBKapiov 




i^^WWil i4IIIJ<lfllJiiT IVUlUAOgioW 




9 1,752 



AooGunting Clerk 


















Oopputeor PtogroBMsiBr 








Engineering Technician 








File Clerk 












Syvtans Analyst 








SOURCE: National Survey of Hospital and Medical Sctod Salaries, 

Onivtsrsity of Tarns Midical Branch at Galvestcn. Hovmter 1986. 
Naticnal airviy Ikofessional, Mninistxative, Mnical and 
Clerical Pay. Meuxh 1986. 

U.S. Oapartamt of labor. Bureau of labor Statistics, 
Bulletin 2271. October 1986. 



Biginaerixig tachnlciaiiB start at aalarlM xoug^y $150 per flcnth hic^her 
than tha aqaivalant alliad health fields; catputcr qperatora start at 
TOQ^y $100 per vcnth lowar^ It will ocna as no surprise that attorneys 
and mginears start at salaries closer to the nan mxiimm rate than to 
the starting salary fdr ipoech l anguage pathologists and audiologists. 

mcxeases in earnings over the length of a career are substantially 
Icwrr allied health fields than in the other listed oooupatiom. The 
salary spread for each of the non-ellied health fields listed, ewoept 
twists, is I jrger than the eptead in any allied health field. 

Ih SIB, the data indicate that although aUied health practitioners' 
starting pey is not al\9dYB oGnpetitive vith the earnings of %iorkers in 
alternative fields, the differsnoes are not large. However, the relative 
lack of a ^'pey ladder^ puts individuals «ho stay in allied health at a 
significant eoononic disadvantage. Although there is no cspirical 
evidence tiiat p ros p ec t ive students turn aimy fton allied health careers 
b e cause of vege ocqpression, it seens likely that students know of and 
react to it by seddng careers vith farig^iter eooncniic futures. 

An iaportant fteAor for enployers considering raising pey to 
allendate pe rsonnel shortage is the %«:th of the job to the institution* 
Ihis fector is faroug^ out starkly %A)en administrators oonsider ttm costs 
and benefits of eoqpandixig the pay ladder, in other vords, peyixqr nore for 
eoqperienoe. In eome facilities, and for seme allied health fieLSs, 
esqperienoe aey be of little value fron the en|>loyer's perspective. 
Indeed, reosnt graduates nay be prefendtde if they bring nore qp-to-<3ate 
skills or the enQmsiaai of a novice. Mxy then ehculd an organization 
reuard experience? Gne answer is the hi^ cost of recmitanent and 
orientation, Li addition, ecne muld say that treating eB|>loyees like 
disposfldtxle objects, not recognizing loyalty or tenure, is sii^y inhianane 
sanagesient, VUrtiMnore, by oonbining ftrrther educativn vith pey and 
career prog r e s sion, quality ney be i(agraded and advanoes in knowledge can 
beocne i ncorpor a ted into the facility's practics, ^Oiis latter point 
beoo p e s Bare important if the stream of ne^ly trained practitioners 
slows, Bqployers %to lust substantially increase pay to attract needed 
personnel aey consider examining job content and restricting tasks to 
ensure that the now more tt^iensive personnel are used effectively. If 
hig^Mr ccnpensation succeeds in increasing by even snail anounts the time 
that individuals renain in the allied health workforce (either by 
continuing to vork or by returning to vork) the iapact on eiqpply can be 

Althou^ supply problens aa^^ be alleviated by increasing 
ouitj e iis a t i on , eeployers way have raasu^ to be reluctant to act. The most 
ftDfideiDBntal and otvious reason has to vith the facility's bottom line, 
Hi^lher salaries not appear justified by the revenue generated for a 
earvioe. Or, the infiact on other occqpations' salary eoqpectatiais of 
raising one occupation's salary my deter eonae nanagers fton utilizing 
this tool. 

Hospitals are facing price ccnisetiticn and prospective payment and 
Iheir financial adBdnistratore feel they ^ave reason to be reluctant to 
incxaaee salary expenses. At a recent Senate Finance Sitamoittee hearing 


- 10 - 

a qpokMnan for tte AiMrioan Hoqpital Aaaociation said that the level of 
Hidioare p ayaan ta oone tra imd hospitals' zevsnias so that nines' salaries 
oould not bs inczeasad (Haalth Ftofassicns R^xxrt, 1987) . HcMsver, data 
indicate that the aarly iMOs have bean xvlatively prof itb:>le for 
hxqpitals. Hoapital qpacating aaxgins— key indicatora of fiscal haalth— 
peakad in 1984 (sse Uble 6.2). Ey SaptanlMr 1987 total cparating saigins 
and patiant rsvanaa qpacating aargins in ooaaaiity hoipitals Mm dose to 
tt» lavals at the sarly 1980s, and thsra vera no signs that the 
dstaadentiun in financial status had oaasad. Howavsr, operating BBxgins 
in tba 1960b and 1970s wars consistently lowr than in the 1980b. Ihus, 
althou^ acBB hoqpitals are zuning in the red, and the situation fbr the 
average hoqpital has dstariocated in the past few yaaxs, hoqpital 
administratars %fith Ibnger mmHas say not be feeling so pressured that 
salazy inczeaaes oamot be considared. 

Ftirthennare, ho^>itals' financial viability rests to a great extent 
on ttmix ability to adhnit and care for patients. Zf lade of staff in ary 
allied haalth field interferes %iith this ability, or slows down discharge, 
an incxeaae in inges is liJoely to be aore than offset by revenue increases 
or derraanee in other costs. 

Ihdsed tiwre nay be no choice for aoployers in need of scartse allied 
health CBcdayees. As ona observer put it. 

Gone are the days vhen doctors and hospitals cou: i 
look qpon Aneriea's bright and notivated wanen as a souroe 
of cheap labor denied eocnonic oi:portunities elssAssrs. 
To attract tiiis pool ol talented tiocfcers into health care, 
we mist get used to the notion al payir^ ccopetitive wages 
(Reinhardt, 1987). 

TABLE 6.2: Operating Margins for U.S. Ooniunity Hcspitals, 

Operating Margin 


Totid Revenue 

Patient Revenue 



- 6.0% 



- 5.1% 



- 4.6% 



- 3.9% 



- 3.2% 



- 4.4% 



- 3.0% 



- 0 0% 



- C.6% 













SCURCE* National Hospital Panel Survey, itetsrioan Hospital 
Association, Hospital Data Oenter. 

^ * January through Ncveqiser. 

- 11 - 

other StzatagiM to Jxacmajm J^-to and Ooofiaticral Tenxra 

A tmrimf of tha racsvit periodioal Ut«r«txa:« of 
bomital adtadnistzatlon reveals acant oowrage of hanan 
zMOUioa wmgenait. Host of that attanticn is focused 
on ihQct<^t«B iasuBs in qpita of radical and longr-tem 
changes in the hospital's environnent as tbki nation 
radaf inw hew health care is perceived, delivered and 
paid for. (Muisfield, 1987) 

So oDsra the zaport of a litacature revlw of the nine mjar 
Ittpital adtainistration and pereomel journals for the years 1983 
thrwKii 1985, fttcinET the ooncdusion that boaan reeoxroe ■enagaiient is 
notVW priority fbr health servloes i^ ene mrlier s nor for their 
auiianae of hMdth care ooKporate eocBOitives and ho^ital 
atkdnistratois. Ihis is a surprising finding %*»en one considers that 
payrbU represents atoit half of hospital eaqpenses. The review also 
noted that of 157 articles related to honan reecuroes, 71 P««nt w»b 
oSoiahBd in ieir«iwy ifanaganant . Our own eearch of the Qaiulative Index 
SfNursina and AUied Health literature (which covers mrsing and allied 
health p«somel) and of selected psychologicBl, oanageoent, and popular 
iKbLiiaSam, «as similarly revealing. Searching literatxire published 
idnoe 1983 on such descriptors as the ooapation titles of eadi of the 
ten allied health fields covered in this report, nnpcwer, tumovw, 
zvtention, and pereonnel, a total of 36 articles were found. Thirty 
zelatfid to nursing. 

Iftnan resource adhninistratare are often in a perplexing situation. 
Ihey aenage a resource that is fundamental to ensuring care of the 
ojantity and ojality daeired by nanagBroent, and tteee cost accounts for 
ainalor portion of the facility's ej^penditures. But, as the caomittee 
heard at one of ite workahcps, dmdng site visits, end throu^^i 
discussiora with Xnowledgeahle obeervers, the honan resource function is 
not often given the visibility or status it needs to perfora its conplex 
job. Moreover, even large health care corparations have not generally 
changed the way hunan - .uurces are aan aged as the organizations adapt 
to the changing health care environoent. 

Hunan resource adnlnistratars are sost often eoipectad to reqpond to 
and lapleBent strategic plamere' decisions. But strategic plans do not 
aluiwBreoognise the comtraints and changes in lakor aarkets that are 
realities fbr hunan resource adtadnlstzatare. If, hcwever, strategic 
wnagnant and hnan reeouroe nnagenent were brouc^ together, eeveral 
bmefits could eraue. Ihe iB|»ctanoe of taaan resource nanageBient as a 
vital part of facility mnagnent would be conf imed. Plans would be 
mmAm ^S5i oognizanoe of litor nrket conditions, and hman resource 
vtninistrators would be in a poeition to act early to ^qplonent plans in 
developaent they have pwrrlrirfitefl. 


- 12 

But, aacv often, pamsml adninistntoni wst tasmblB a labor 
foroa to pcQvlda Mrvioes, as duclded by othar adninistxaton. It is 
not until labor sarkats baoona ti^ that upper ■anaganent aqpports 
serious efforts to retain and attract allied health practiticners. 

The previous section sunested that incraased pay would crtianoe 
simply. But aoray, although Lqportant, is only one of thm nary factors 
that BBka «q;iloyBiant in a field an attractive alternative to leisure, 
home activities, or anoOier types of vployDBnt. Miat afikes «q;>loyiDent 
attractive? liiat w o n ■on ^ tary aspects of a job oauae satisfaction or 
dissatisfaction? Ohe knovledga base for a ns w e ri ng these quastiens 
about allied health fields is qperae. A review of the gnaral job 
satisfaction literature notes that aaqalanations of dif f erenoes in 
satisfaction are usually related either to individual characteristics 
of yoaOoBics, ixduding their needs and values, or to the nature of tt» 
jobs and characteristics of eniaoying ocganizations (Hanson et al., 

Biplc^arB ihould not assma that factars tiiey oamot control, such 
as family raeponsibilities, dondnate aii>loyee decisions. A review of 
studies of self-zipocted raanons for resignation of nurses notes that, 
at least ona^third of resignations resulted fron job dissatisfaction, 
and a reoent stud/ attributed three-guarterB of "oontagplated turnover** 
to job problenB (NeisaBan et al., 1981). 

MackBTB' job regudraaBnts are loiown to vary according to eex, 
race, age, and eo on. Ihe Hudson Institute in its project nibrkfaroe 
2000" drev some oondusions about wooicfaroe proialans that aoplcyers 
will have to address if tiwy wont to hire the wockerB of the future. 
With the increasing age of the wozkf orcse they aust be ooncsemed about 
these imrkets' adaptability and willingness to learn. With regards to 
%«rking vcmbbr, rafom is needed in day care, tine-off , policies to 
assist welfare Bothers in entering the labor foroe. Ohe full 
utilization ot the wakfoioe will require integrating blacks and 
KiepanicB into tha labor aazkat, but that aeans overooning the fact 
that they are also least advantaged in society with raepect to skiU 
levels and educational bac9agp?ounds (Hudson mstitute, 1987) . Btployers 
wocking with ar. allied health w or kfot oe tiiat is largely rmrnmifl of 
wonan %iill want to pay attention to findings about «hat aakas a job 
appealing to wonsn. Seme suggest that women's unique wock needs stent 
ftan their dual raaponsibilities at home and at work. Studies indxcate 
that f actora such as txaval tiae from work are aora iainrtant to women 
than aen. For thjse woaen ito are not career aotivated but aoce 
interested in 8t4]pl<">"nting the houeehold inocae or getting out of the 
house, jobs that suhstitube other rewards for advanoament, stabixity 
and hig^ pay aay have attractions (Hanson et al., 1987) . Sena 
dif femaes in wockforcsa behavior between aen and women include women 
being less likely to raain in one occupation and one particular job 
than aen, and having aore ftequent career intemptiom— although 



- 13 - 

this lattar 6iftmrmncm nay te dlsdnishingr* fkmen pursuing longer^tem 
carmrm an 1ms likely to dif f «r trm men in the f actats that 
oontxibute to job satisfaction. 

For nny vartais satisfaction, dissatisfaction, and decisions to 
leave or stay in a job or field are related to factors to do with their 
tads; hon tfaey fit into the organizational structurs; and their 
e)qpectations about ttmir oonditions of %iarfc« Ihe nursing literature is 
replete with analyses of reasons for diseatisfaction—baredcn, linited 
possibilities for advanoflnent, lack of status, not fully using skills, 
lack of fdrtfaar educational opportunities, lack of autonony^ prcblens in 
relatioraftiips with piiysicians, and staffing patterns that do not allow 
fbr ttm provision of hi;^ quality oare. (See for waaflm PrixM and 
MMller, 1981; Waiflnan et al., 1971, and a review of tte literature that 
notes that svery sajor study sinoe tte 1960s has pointed to the fte:tars 
of autonomy, interp^viocnal relations, and job status as critical 
ocnixmnts of job satisftetion. Institute of Hadicine, 1983) • 
Sa^sfaction often stons fkon recognition by peers and sqpervisors, 
profeesional growth, feeling i9|xxrtant to patient cars and to the 
institution, and involvnent in decisions concerning both patient care 
and institutional policy* An analysis of the isportanoe of these 
factors in determining turnover found that autoncny is the s tr onges t 
predictor of job satisfaction, and the supervisor's responsiveness to 
the nurses' work and conBunication needs is tiie best predictor of a 
sense of autononiy. (NaisDan, et al*, 1981) • 

Findings of this sort have generated nanerous strategies (not 
always adcpted) to enrich nurses working environnant in order to extend 
both job and occupational tenure* Strategies include creating 
decision^naking lixdcs between the chief executive officer, nursing 
service administrator and staff nurses; introducing primary nursing and 
dsvelc4>ii>g patterns of tqpward nobility* One inportant difference 
between nursing and allied health in this regard is that althouglh allied 
haalth pnctitioners hold adninistrative jobs, sanaging laboratories, 
dietary services, radiology departments and so on, there is usually no 
isobrella allied health administrator position to pranote the interests, 
and raise the level of visibility of the allied haalth workforce. E^^ 
way of contrast, hospitals ccnmonly have a director or vic e p r e s ident 
fbr nurs^, and increasingly they are assuming even broader 
responsibilities such as vice-president for patient eervices, whidi 
scnetiiDes subscanes allied health services, Hha fragmented, diverse 
nature of allied health makes the developnent of a unified power block 
within inetitutiora difficult. Establi^iing the linkages to central 
administration that have been helpful in a ddre ss ing work environnent 
issues fdr nursing, is thus inhibited for allied health. 

The nurse-physician relationdij^p is an iB{)ortant factor in 
the way nurses perceive their roles and satisfaction. For many 
allied health practitioners, physicians too play a major role in 

o 243 

ERIC . ^ 

- 14 

9Bn«niting an wiranMnt that will Indkioa practltionexB to extend their 
t«ura. Rqpoo±ing on a suooanful affort to lingthan mram' tmixe one 
luralng aiteinlstrator noted: 

Iha pIvBician'a i61a in nuna vatantion oannat be 
ovaratatad. itian ttwra is doaa rrM»T ^ ^/^j^ batueen 
phyaiciana and nuiaaa, an incamaad lav«l of satisfaction 
fdr both parties is avidmt. Hothing anhancM the zola of 
the nana aa nxti as awBTinaaa that a physician is hearing 
her paonpactiva of a patient care issue. Orthopedic 
phy>icianB and oocthopadic nones slniltaneously nqiMsted 
that nuning practice be caqpanded to include acce 
activities. Nursing activities then «en planned anl 
inplaanted as a joint vantun. (Araujo, 1980) . 

Reports lite thase apeak to the iaportantsa of facility adfaninistntars 
encxxsaging physicians to be involved in effoorts to extend tenure. 

Also of i n aot tai fcja is the role of rasearch. Rxwledge of the 
factocs that pft r aiiad e practitionan to leave or st^ in their allied 
health field could ueefUlly be expended— and «hat seeas obvious is not 
a^^ys the ri^ annwr. For aoeenple, a anall study of ivmout among 
reqpiratory care penomel found, to the author's auiprise, that hours 
%PQaicad per ihift or per wade, ahift assignnent, £re(]jency of rotation of 
daily *wric assign- aents, variety of procedures perforaiBd, or treataents 
par ahift, did not relate to burnout. Lower burnout rates were found in 
pnctiticnere with hig^ eduoati^ial levels, a greater sense of 
autoncny, and perceptions of hi^ quality work being done in their 
departments (Shelledy and Miklas, 1987} 

But, just as vitti aalary decisions, it is unreasonable to aoqpect 
facility adtadnistraton to sate changes not in their iistitution's 
interests. Althou^ providing opportunities for i^Mard nobility is 
generally seen as an i a poart ai i t elaaient in generating job satisfaction, 
there are clearly liaits to the nmber of hi^^ level practitionera 
needed. Jn soaia cases any surt of inward mobility nay be iapracti- 
oabla. Ab an alternative, «B|)loyBn nay finl that encouraging an 
aaqpansicn of ridlls to another area can sustain aployee interest and 
extend tanm in wock that could beccne tedious. Hethodist Hospital in 
Indiana ^maora a progrem called "Add-A-Ocni)" that enables individuals 
with health care eoqperienoe to acqiuire additional oonpetancies. Ttu^ 
fulfills oiployen' need for cxoas-trainad personnel. Moreover, 
enployees who are nora challenged and stiaulated are less likely to 
leave an eaployBr or the wockfocoe. 

A secondary benefit of iapxndng job satisfaction will accrue to 
•qployan interested in avoiding unionization among their cnployees. 
Health care union nenberdiip, which has been 



- 15 - 

xiAing dvpittt a mticnal dKlim in othttr union miterdilp, stands at 
dtxsut 20 pmx m ± nprssantaticn. Rwant organizing issues 1ibv« 
Includsd qMBlity of lara, quality of vork, stzws, job rastructuring, 
anl bsMfits. Barwisa of siailar OMioams vititi issuas of ocB|»sation, 
job saourlty, and iMningftil %iotfc invblvnnt, ptofassionals and iihite 
ooUar WQckars ava idantifying vith blua oollar vocksrs, and 
identifying vith inionisad groups (JkBsrican Hospital Asaociaticn, 
1986) • Ihus, aaployacs cannot raly on aployaas' sense of ptofessicnal 
status to araid mionitation, Scwvar, ky sddng adaptations to 
incxaasa job satisfiacton ttaey are attmding to issuas that aiig^ 
othemisa result in union ac±ivi/4:y. 

LcMer*lsvel faaaltiti oara practitioners, such as orderlies and 
technicians, have nagotiatad contracts tiiat induds retraining ptcgraaB 
in case of layof f • As a result a hoqpital has started training 
ptugra a s for sterilisation technicians and licaneed practical mrses 
(lunaar, 1987) • Organisations that hava thaea aort of contracts have a 
read/ pool of iiorlQBrs vhosa training can be charmled towards skills 
noortpfl by the facility. Thus, althous^ unionisation can radme 
oployeKs' ift>llity to redesign jobs and raduoa norkforoe flexibility, 
it can also on oooasion incxaasa the options in uses of sanpcMer. 

Job satisftiction also ralatea to the socialization into the 
profeasion that occurs during education and ccntact vith rola acdels. 
Ihis siTrlaHrrfttlff) vphasizes the iaportanoe of ^puard acbllity. 
Studies of nursing indicate that the hi^jhar the lavel of education the 
graatar the liJoalihood of job dissatisfaction (MaisoDan at al., 1981) • 
Although this could be related to ffcustrations that occur if 
^practitioners do not ftdly uee their akills, the lemian-h findings of 
job dissatisfaction relating to tpward eobility, role, use of ekills, 
and autonoay, all point to the conclusion ttiA warn discnpancy exists 
bet wee n what enployers nasd and the aspirations and needs of graduates 
£ron educational programs. Mare axtensive ocnnunication between 
educators, a^>loyerB and profeesional essociations ad^ help to 
improve ttm fit between needs ef an{doyers and their eaployees, and 
thus help extend job and ocopational tenure. 

The problan of aatching education vith work place needs is also 
a'l nr"'"* in Chapter 5 of this report, vhere education issues are 
discuesed. Ihat chapter contains a reccnnendation that the groqps nost 
influential in developing worksite tasiks, curricula, and aqpirations- 
-the triuDvirate of educators, Mplo^^n, and profeesional 
etTTtflit i ^ " ■ ■» ^v>n<^ gre8(ter interaction. Cne aperlal problem 
that »i^ be adJieeeefl by the group is to attapt to ensure that the 
diversity of enployers' needs are aatchad by the diversity in the 
education of pcactitionars. Allied health jobs exist in naaarous 
aattinga hoapitals, nursing hoaiee, prinary care practicee, etc. 
Sattinga vary in ttiair need fdr different rargea of skills and 



- 16 - 

and levals of mnptrtim, cvtn in a a^ngla flald. Raflecting this 
divvtsity in tte o a it a i it and Icval of adacaticn p to gtam would help 
incTBaaa job and oocqpational tewra fay aatching pnctitionen' 
abilitias and aq;>iz«tioni vith potioit and ixstitutional naeds. 

Anothar iaaue that oould uaafuUy ba ^dra aa ed fcy aaployen, 
profassional aaaodntiona; and aducatocs also relatas to prv'^waicnal 
aspixaticna. AlliacI health pcactiticnata vcoddng in health cara 
fiK^ilitias of all typaa baoena part of a laxgar groiqp of vcckan vith an 
ocganizstionBl stnactura. Otoa 'tedical ■odel" of autencncui <«ark, «hicii 
is pixaiMl fay aany phyaioal therapists, qpaach-languaga pathologists and 
laboratory t«±nQlogista %te baooaa ind^pandent oonsultants, is not 
always aithar vaalistic or attainabla in ooniilax aadical aettings and 
for Bost practitionaxs. lhasa practiticnars iwed goals that provide 
satisfactccy altamativas to indapendait pcactioe. 

A further alcnint, alraad/ touched on in Chapter 5, is the 
provision of clinical sites for education, ihe nater of health care 
facilities providing sites for the clinical o uukj i whL of education 
prograns is decreasing. BiidoyerB ihould ooralder that the cost of 
prcviding clinical educatioTi is in the long run often offset fay a 
bolstered sqpply of practitioners and avoidance of personnel shotrtages. 

Erhancing the Uee of the E)dsting Worfc f oroe 

Easing scarcities in the siqpply of allied health practitioners by 
expanding educa t i on al capacity is a strategy that only begins to be 
effective several years after initiation. More ianediateiy effective 
%«uld be extending the tenure of existing warkers, and bringing back 
into the wockfocoe individuals who have choeen to leave it. A different 
approach is to eKamine ways of using the existing uorkf oroe more 
productively and effectively. 

In the early part of this chapter it was noted that when donand for 
allied health practitioners exceeds siqpply narket farces will drive vp 
the amount t^at eaployers will have to pay to hire the needed 
pereome} Ohis will in the long run ia^iKove smsply. It will also 
diTnl'nIwh urn tqpward thrust of deaend as nplcyerB, vith a acre expensive 
inckforoe, seek ways of containing this asqpense. An approach that has 
the potential of providing a dual benefit— incxeasing jcb satisfaction 
as %«11 as using staff anre efficiently— is xestnicturing of taaks and 
■taf f daploynnnt. Ihis xeguixes that a ainistrators ahed traditional 

of thirddng dxut individual and dapartaaBntal T*q*mff1WHt1fw. 
Sonetines eaqpanded roles for lower level staff will allow aore flexible 
staffing of units, to the extent that regulation permits. firMw»ipof» it 

o 24G 

- 17 - 

is possible to aatoim tasks to fdm a rmt, ailaxgad, aodula of vatic 
Oiing aultidiaciplinaxy taans can lacsak down dqpaxtnental bcuriers to 
kllotf wHargtd aghnm of zwpcnslbility for individual sta^.'f. Ifeuiy new 
oonfiguratiois of taAs and staff ava possibla, taut lust b3 prooaeded by 
»n invsstmant in hooan xssoutoa staff to oigage in tiie naobssaxy 
irndtBMRtal analysas and vaOiiiiking of taaks. 

K fmniHar indostxlal rsi poi isa to satficMar tfuctages or peraptlons 
of ovarly-fai;^ psxscmal aqpmsas, is to txy to iqprov* labor 
TSKcOodtivftf, HcMBvar, than is a ooanan pawption that thi» serviae 
siictar of dm aoonoBy has v«iy lav mt^s of prodkictivity qea&h (nitdMr 
And Itoxk, 1983) and ttoat haalth o .iaus« it raqoixas a handa-cn, 
cn a cn ona anproach, is not oanah. ' > .«oasurss to imaase 
f^. ^4activi':y. CartairJy, if oparatiii^ sargins oontinia to detaaricrate, 
''\ smum r.aasonahla to aiqpcct aaaini sLiatuts to saak %«ys of isfsoving 
pecdbrtivi^ If tmalth cara is viewad not as a «hola, but xattrr as 
indi\idual apacdiic sarvioas, some araas appear to have potantiai for 
productivity gain. Ona of the often cited areas is autonation in 
liiboratories • 

Ibdi^'s financial inoantlves to tBSoca oast axe coqpected to 
anoouxage the davelopnant and l 'j^tion of technologies that iiprove 
productivity. Sobm stnictuxel >itianges in the health oa^a is 
daiiverad also have potartial for prriuctivity iqprownant. For 
instance, laiija si Blea^ia.IalltuiJ delivery sites, such as qpecial suxgezy 
cr iaaging mits, aoy be ^ble to xeap enrrrmles of scale in the uae of 
ptrecnnel. However, it is tnliJcely ttiat changes such as thetje %dll 
outweiq^ ether cha nj as such as the aove to hone aerviose, and the neu, 
onplaae technologiee— that use ■arpouer in a leee productive aanner. 

GroBs-^trained or aolti-ouiiietflnt allied healtii pexsomel axe 
ocnoepts that have been rtlanmwwd for nary years. Ih the past the 
ocntext VBS xuxal haaltii staffing proialaBBi. Today ttey are aaen by nome 
as imovative solutions to ihoctagas of persomal, eapecially in wubl}! 
hoqpitals, physician offioas and other a* all delivery units. 
Malti-ooBpeitent persomal are also regarded by son* larger hoqpitals as 
eoonoBiical souroas of staffing neadeci 14 hours a day but with loiMJse 
pviods. More gmarally, as revwua res orictions foroe aAninistxators 
to aocaaina %iays of controlling labor aoqpenees, aaployBrs are beccndng 
interested in incxeasing labor productivity by decreasing 
specialisation, as evidenced by the ADsrioan Hoqtital Aaeociation 
^poneoring a nsiaer of uoclahops on ^ aulti-aildlled concept. A 1986 
national survey of sadlnal laboratory annagars indicated that 46.3 
pertx<it said that tiiay could use cross-^traLnad persomal (irtrous^ 
1987) . A survey of hiaq>ital adhninistrators, directors of nursing, 
direcbon< of oouunity healtii organizations, and physicians in 
Riiladelphia diowed that Bilticoqpetant practitioners axe alxeady 
flsployed in approodaately a quarter of ttm hospitals. Sixty parooit of 


- 18 - 

thB ^jMpital adadnlBtntan villing to imv mni'Miir ^iH ri 
pmctitionm now {hja and Miijtecd, 1987), and •dtmtots npoct that 
thair Biltloopqpatant ^raAiatas gmerally find jote that ma thair 
tnlning (BSkBjnef, 1982) . OalnBr aulti-cxncMtant Fractiticnara is not an 
all-pjzpoaa aolutkn, but it zi(jaMnfcci tha raaults of an af fort to 
think tfaro ujjh tha t art» that wat ba par f oraad, and hew tha aducaticn 
ayrtfli can raapond. 

RoSuctivity in wMiita, howavar achiaved, ava dafinad as 

dacxaaaing tha iifut par taiit of output, nua wa aay that prodkictivity 
is incxaaaed if a labocatecy wocfcar Im lanaaa tha nidbar of tasts 
pa r foa ia d par hour. Mothar way of thinking about hov bast to i»a 
alliad haalth aaifnuar and iqpKova pcoductivity is to xadef ina output in 
tarss of oontritauticn to patiant oara. To aska this dafinition 
qpamtional, ona mist svaluats affactivmss. Output can be inczaased, 
and praaauras on sanpoiMir aqpply can ba reliaved ^ reducing aarvioes 
that fail to oontributa to patiant welfare. 

aiggastlona of lanaoaaaary oaxe (or at laast lac^ of agrasment 
abcut appropriota oare) are found in studies Stowing variatiow in 
aeounta of aexvioe aooig nationa, among zegions in tha aana oountry, and 
aaofig diffanwt typas of c^'9Hnizatiaia. But tha idsntification of 
effective an ineffective oare fcy allied health practitioners is not 
plantifUl. Shroedar (1987) reports studies that have detected patterns 
of overuae. Overuaad pcooeduree or tecimologies, aoaording to thaae 
studiaa, incduda %«iite blood oeU differantial counts, aaaauraeDant of 
aerun lactic tkhydroganaiie, blood ckobs natch, barium araaa atuliaa, 
vfper gastrointsstinal sariaa, nursing attvioa arders, tonsillactcnry, 
chast x-rays, prescription drugs, preoperative eczeening tasts, and 
thyroid function tasts. Shroader adds, 

A recent study trm our institution estimated the 
proportion of redundancy among a wide variety of diagnostic 
and nursing sarvloas fac patients on a ^Bmral luadiced 
lArd. Of the more tlian 8,000 sendoes ordeored fbr 173 
patients during the obaarvation period, 21% ware judged to 
be wneceeaary by faculty auditors «ho reviewed tha medical 
xeoocda. Ihe most overueed eervioee were partial 
thronboplaatin time (daaaed unneoassary in 63) of uses) , 
atat/coiargency ocdars (43%), nuclear medicine stuaias (26%) 
and platelet oounta (25%) . 

Another %a:y of assassing ovenxtilization is by 
determining whether dinioal services contribute to pav:ient 
laanagenent. Reports fixn several teaching iistitutions and 
one ccanunity hoqpital ahow that as ftaw as 3% to 5% of 
diagnostic tests are actually used in the mr»fjmer± of tha 
patients for when HMy are ordered (Shroeder, 1987) . 



- 19 - 

Vnbably Jw alllad health Miviae aost atulied fur overMxtlllzaticn 
u Mm diniool labocstary. on* analyst auggasts that araurinj 
•ffactivanaas is in part tha ra^xiwibllity of lidxratory ociantists yAso 
ttaaOtak a vatmt at quaatioro such aa ia tha ocdarad tasta is 
anpanpriata for tha patiant'a cUnionl condition? Miat lavel of aocxiracy 
and pvacisicn ia naadad for dinioBl judgment (Barr, 1987)? others are 
yooMiq to develop Mthods for detacting ovarutilization (aee for axancle, 
Eiaentiarg, 1982 and Gaig at al., 1985). 

Mary qaaati cna about •ffactlvmesa icaaln unanswexad today. If cost 
oontainMnt praawraa oontinia to acunt, soma a.^loying organizations nay 
initiata naaarch. »Da nay ahift thair foos trm a ooncsitration of 
radocing hoapitalization to reducing ineffactivM car« in other araas. 
Other proapactivaly paid providara too hava reaaon to tiy to alininate 
aoiDaaa aarvicas. 

Finally, sobm allied health practitioners aay want to undertake 
•ffactivanaaa i^ o m i .h to affirm their plaoe in patiant care. Uhtll that 
is done they way be vulnerable to cuts by institutions seeking to reduce 
personnel expanses. 

Biploysrs With Special Problens 

Sone health care providers are particu'^arly disadvantaged in the 
conpetition for allied health practitioners. Ihese cnployers vill find 
that for one reaaon or another they cannot inplenent many of the 
strategies rtlsCTWsed aarlier in this chapter, m this section ve will 
discuss the predioaB«nU of two of these nplcyers— rural health caxe 
facilities and nursing hanas and other long^tem care aites. m will 
wggest aone strategies that may be useful in trying to ocpe with their 
needs for allied health nanpouer. 

Rural Health EBK^ilities 

Aooording to the U.S. Bureau of the Oednsius, over a quarter of the 
population * the Uiited States is in rural araas. Ihese peq[)le live in 
araas that «^fer frcn other parts of the nation in many aspects, and 
often these differanoas have iBplioations tea: the delivery of health care. 

The definitional and not uninportai.^ difference is that rural areas 
are acre qparaely populated than urban localities. Fswer people live in 
the catchnant area of a rural health care provider. Ohe population is 
■on' often poor (14 paroent below the povwty level ocnpared with 11 



- 20 - 

pareart in wtnpolitan ams in 1981) and alderly (13 paiomt over 65 
ooparad with 10.7 paromt in 1980) , and thar«forB has dif fennoes in 
haalth statxw and haalth oava naeds. ExaDples of health status 
dif f«r«no«s include hi;^ zural infant Boortality, hi;^ incidsne of 
hyp«rtansion, coonnaiy heart disease, •oiih^'Beca, and scne otter chnnic 
conditions, but Iowbt incldanoe of acute conditions as a vhole (Omdes anl 
Nri^, 1985). 

6cB» of these difftemas say relate to dif f eraRaes in health care 
■ervices anmilable to zural populations. Oha hoapitalHbed-to-population 
ratio does not differ mxh hitssssi zural and nonzural areas, thanks to the 
Hill Burton Act of 1946. Ljt the sifply of health pcofessicnals in 
relation to population is less in zural areas and so is the range of 
sezvioes offered tay hospitals (Gocdas and Nrlght, 1985) . 

lhat these zural hoqpitals have special proialans is well doc u men t ed. 
Of the 5,732 conunity hospitals in the ttiited States in 1986, 47 percent 
v«ire zuzal and 17 peroint had fewer than 50 beds. Eicfhty percent of Goall 
hospitals are zural. Staall hospitals anywhere are nore liksly to close 
than larger hospitals. Of the 214 connunity hospitals that closed between 
1980 and 1985, 75 percent had fewer than 50 beds; 86 ware zural and 128 
urban. (Haalth n eei jmr es and Services Administration, 1987) . 

Ihe raasons for vulnerability aC zural hoepitals asy relate net 
only to their zuzal charecteristics, but also to saallnees. Analyses of 
Anerioan Hospital Association data (Ttable 6.3) ehcw that bstse^i 1980 and 
1986, the analler the hoepital the greater the deterioration in sevezal 
Joey indicators of strength, qperating nargins, admissions, and ocofiancy 
have fallen acre and are lower in egnaller hoepitals. These data t^n %Aiy 
raising salaries to attract allied health practitioners is not feasible 
for sany nail rural hoepitals. 

Attracting practitioners to rural aplcyment is nore difficult than 
to other settings. Table 6.4 een^ssts the practitioners to population 
ratios in netropolitan and lun-iuBtropoUtan settings for sone allied 
health purofessions. It is evident thar metropolitan areas in 1980 had a 
nore plentiful sqpply of pcactitioners in all the listed fields. Ihis 
loMer rural mncentzation my in part be di» to the lower ooncentzatlon in 
zural aracs of seme of the individuals and organizations that usually 
enploy allisd health practitioners— den t ists, physiciaiw, and so on. But 
with the hoepital-bed-^ t o-population ratio quite similar in rural and 
nonzural areas, the usual enployerB of the najori^ of allied health 
practitioners would seam to be present. 



- 21 - 

T!^BL£ 6.3: Selected XndicatorB of Hospital Strength 

Change Act^Md 
1980-1986 198b 

C|)eiBting neucgin: 

all hospitals l.o 5.4% 

hospitals vith 25-49 beds -4.8 1.5% 

hospitalB vit^. less than 25 kieds -4.5 -6.3% 

all hospitals -8.0 
hospitals vith 25-49 beds -39.8 
hospitals with less than 25 beds -44.8 


all hospitals -16.1 63.2% 

hospitals vith 25-49 beds -36.7 33.2% 

hoqpitals vith less than 25 beds -31.7 27.4% 

SOURCE: Health Rasouroes and Servioe Administiaticn, 1987. 
Rml Hospitals/Health Sezvioes. l»-«ubliahed. 

For zuk»l hospitals allied health eiplcs^nent problenF n be viewed 
in three ways. Gne is prcblcBS in attracting practitioner ^ rural 
enplcyinent. The seoond is affording the practitianers. Ihe third is 
finding practiticners with the education that suits than for rural 



- 22 - 

IMOE 6.4: Geognphic Distributicn of Sel«cted Allied Heidth ProSfsaiars, 

Allied Health Profession 

Water per 100,000 
!ion-4>ecro nbczd 

Dietitian 26.0 30.9 

Speech therapist 14. 4 19.5 

Health aide, eoccaept mning 99.9 138.5 

Inhalation therapist 16.6 23.1 

Dental assistant 53.2 75.2 

Health reoocd technician 5.0 7.2 

Radiologic technician 31.0 46.3 

Riysical tiierapist 12.7 21. 1 

Clinical labocatoty 

technician 68.9 120.5 

Dental hygisniet 12.3 23.1 

Ooa^tional therapist 3.5 9.3 

Non-oetro ratio 
as peroent of 
■etro ratio 




SCURCE: Review of AUied Health Education: 5, Ed. Joaegti ftaakueq, 
Uiiversity Rness of Kentud^, 1985. 

HhB geographical naldistribution of personnel in seme health care fields 
has been %«U studied. Lass uork has fiocuaed cn the aaldistrlbution of allied 
health practitionen. Sens lessens can be draun ftcn vhat is known lOxut other 
types of health care ptactiticners. Allied health education, like mast health 
care education, takes place prinarlly in aetaxpolitan areas. Most often 
clinical CDverianoe is provided in acute can settings with the patimt volume 
needed to sifpor* statft-of-'Utt-art, hic^ technology services. Graduates are 
wbseguently drab.i to aaployBsnt in similar settings for several zeaiwns. Thev 
perceive these settings as offering hig^ quality cars, perKral challenge, 
Aill use of their aduoation, and the stimlation of contact vith paexs and 
aqperviMars. contrast, to a cit^^-xeasad votkar, zural facilities axe an 
uhknown setting, perreived as iscOated, backuazd in tem of technology and 
with litUe room ibr advanoanMit in their fisld. One lesson fran studies of 
health peraomel education and Mplcyment decisions is that graduates who grew 

in rural areas or ttose education indudad flo^erience in these areas are 
aoce likely to ctoee zural atploynant. 



- 23 - 

individuals iJhcsm roots an in zural araas can find the flonetazy and 
p^diological cxxit of attcnling sAimtlon programs in me tr opolitan * reas 
prehibitiva. Mking admtion to rural araas would help taring theeu 
individuals into ttm allied health workforoa. Such techniques incaude the use 
of taleooBBunications technologies and ^circuit riding** faculty. BqplcyerB 
oculd assist such effbrts by mcxuraging q|ualified allied health staff to 
participate in teaching. Ihey could also prcvide classrocm apace and clinical 
eoqperienca in their fSacilitiee. 

Ihe enployar's rble in increasing Urn singly of graduates trnniHar %dth 
zural settings Is tteis twofold. First, to %nrk %dth local hic^ schools and 
career oounsellora to enoouzage students to pursue allied health careera. 
Seocnd, to work vith allied healti> eduoatots to provide clinical a9q;«rienoe in 
their fteilities. 3h Alabama a oonsartim of junior colleges and the 
lAiiversity of Aledbama ws ftmnad in 1969 to enhanoa the supply of allied health 
practiticnars in mderaerved areas. As descrrihed by Keith ELayney, Daan of the 
School of ODnnmity and Allied Health at the ttdwsity of Alabama: 

m 1969, the state's jtmior collega presidents and 
tepresentativas of the Itaiversity of Alabama in Bizning^ham 
(lAB) Mt and endorsed the c otKa e pt of a consortium to link 
the two-year echods with (AB. Ihe benefits %«ra readily 
apparent—lay Aaring students vith the Ragicnal Tecimical 
Itetitute (REI) at UAB, the duplication of specific allied 
healtii progra m s and their hi^ costs could be avoided. 
Also, students could attend school near their hcoas for the 
first year of the program. After the saccnd year at RTI, 
graduates %iera likely to retuzn to their hones, located in 
the aedically undersezved araas of the state, and prcvide 
ancillazy support for aedical services there. As the 
p r ogra m develqped, efforts were made to eetebliA clinical 
training sites for the students in or near their hones, 
dais providing en additional iapetts to zvtuzn hcne. 

Before their year of technical training at the RTI 
ends, the students wpeanA six to ei^ weeikB in on-site 
clinical training. Although the RTI is located in the 
hnrt of UAB's Midi«l Oenter, iiteze ttmn is a large 
^^una and variety of clinical materials, it eocn became 
clear that the Modioel Qonter alone irould not be sufficient 
to provids adaqiUBte mperienoe for all the allied health 
s'judents. As a result, linkage students can now conplete 
the last veeiks of their clinical training at nailer health 
care fteUities throug^nit the state. Iheee facilities 
range fttn doctors' offices to nursing hones, clinics, and 
hoapitals. Ohis arrangnent has other advantages, ihe 
students can woclc dose to their hones, in ficilities 
sinilar in size and ecope to thoee in %hich ttmf yill 
probably vork. Also, upon graduation, ths students are 
often offered positions at the facilities itera they did 
their training. 



- 24 - 

Sinos the noter of cllxdcal facilities has been 
eoqpandid, a hlgtwr p eo r oont a ge of RTI graudates have 
returned to niral areas to %iork. Jn HTJ, 59% of graduates 
of piuyiaii tliBt tmm clinioal training sites outside of 
Biming^ham took jobs outside of Urn city, vhile cnly 34% of 
the graduates \to had no clinical af filiaticn outside 
BizBins^ left tte city (Blatyney, 1981) . 

An evaluation of the linkage laugran after U years found that 66 
peroan t of the graduates ito rsDained in allied health retumad to their 
hcma county to work (Obqper, 1982) • Clearly this aodel raqiuiras serious 
ocnndtaBnt hy eaployers and leaders in educatiGn instituticns C amUJ ^IwoI 
with and %rilling to help rasolve sooa ptohlons of rural care. 

Another type of lirikage vould be ftar rural enidGyers to errange 
regular, periodic s e aun dhig iit to an urban facility for tiieir allied 
health «s|)loyees. Arrangsmmts %dth educational pro g ran ^ and leaders in 
allied health fields to provide lectures or soninars to practitioners in 
rural areas ni^fht also help dispel some fears of isolation and ensure 
that practitioners are kept up to date in their field— as vould generous 
allcuances for continuing education. 

Itoal Mployers operating lev vdvam facilities that cannot afford 
or fully use a foil-^tiaie staffer can aleo try to develop linkages. In 
Nisouisin 22 aoall rural hospitals have fomad a cooperative that diazes 
services, sobile technologies, and professional stc^ff , lyho travel among 
ho^itals (Health Resouroes and Services Ackiinistration, 1S97) . 
Employer initiated during (as oiposed to eRployees vho find several 
part-tina joIds) say also appeal to practitioners because the/ get 
full^tina enployment and benefits that are often not ctf f ered to 
part-tine onployees. 

A further model of oooperstion among eaployers is the organization 
of eervices on a regional basis with each hospital qpecializing in 
certain services. The Robert Hood Johnson Foundation is offering grants 
for this and other models to help rural health providers with financial 

Ihe notion of im i ltliurnHle i iL personnel is frequently suggesteJ as a 
solution for loihv^me rural providers. A flnall nja±ec aC pr o giai n s 
training multioonpetent practitioners exists. A pt og ram providing dual 
certification at SaMtmm Illinois Uhiversity at carbcndale, started in 
the 1970s, is popular %dth rural oonnunitiee. Recently, however, 
students have souc|ht oertdfication in only one field, ihis is though 
to be because single field jobs pay better (Oortes and Mri^, 1985) . 
As ve have noted, the ebility to pay ooapetitive salaries is likely to 
be limited in rural locutions and is ^'^^^^ ^ on r^isBbyrMnait 
decisions. But ii bse n t attractive coqpensation, efforts to ease roral 
manpower ^jroblenm will fail in the long run. 



BBDplcyvrs dMiring ■ultiaoqpotent practiticneni can help lay 
«raurixi9 that «kaoaton know that donemd exists, and also mJdng known 
tha six of ooB|)8tsncias thsy naed. If an Individkial's adbcatlon is 
tailcrad to an mfHaftr'n raqairanents ttm aqployar can use the 
practitioner efficiently, and thus ewy1w1r,e salaries. 

Iha third iypt of problflB of rural health providers- 
-f iitUng allied health pemmal with the qpecial aldlls needed for 
eniiloynBnt in flBBll lurel aettinge— can alao be alleviaited by linkage 
vith eduoattioml pcograos. Again, pxivlding dininnl sites for students 
erauces that they learn rural practiae. Nodela already exist. Me have 
witionad the Oniversily of Alabeea'e Lihkage Rnogram. Htm university 
of Wisooniin Madioel TKhnology Program pleoae stur^mts in a ganeralist 
oqpacity in anall hoiq;>ital lahoratorles. This program is said to have 
contritoubed significantly to the interest of tiie student in clinic^ 
Idsaratogiiee in ocamnity and rural ho^tala es the majority of 
studente hove bean «|>loyed in such laboratories after grackiaticn 
(Bariaezg, 1981). Another model offera students e) q per i enoe on health 
care tea» in rural Kantud^. Students at Kentud^ Southern Oamunity 
College are eaqposed to rural practice and learn how to function %dth 
others on the health professlcn team (Banterg, 1981) . 

One type of linkage already in place fbr acne rural providers is 
■eniserriiip in a noltiprovider organization. ReganUees of %Aisther this 
organization is horizontally or vertically integrated, if both rural ond 
urban sites belong, an opportunity for inncKrative solutions to staffing 
problasi eodsts. Ruical meriaers of the organization ru^-t negotiate 
arrangmnents whereby servioe at, or rotation thraugki, a rural location 
y^mfmnm ^ B naoeBsary mtap in ttm tqpMoxd career ladder of the 

Long-Term care Facilities 

Long-term care providers (such as narsing hones and chronic mental 
care faciliti-es) , similarly as rural health care providers, have apecial 
characteristics that make ecee of the strategies suggested in the 
earlier part of this chqpter inapplicable. It is difficult to increase 
tBlfiri— to attract allied health practitioners whan raiBbursenent is 
eoctranmly tic^. It is often iapossible to provide paths to advancement 
in ■nail facilities, which tViTllinn naiiy nursing hones. 

Chqpter 8 eoqplocee zeeeone why long^ezm cere facilitiee are not 
•aen as attractive worksites. Some of ttm reasons are subjective and 
perceptual. Ihe care of elderly patients, and those with chronic and 
amtal iHsannne is ssan as uneatisfactory ooopared with working with 
pati«its in whom reel and lasting tunx w i n e n t can be realized. Mental 
disturfaenoas of petiants sBdce practitioners' tads more difficult and 
are a condition for which aAxation often fails to prepare then. In 


- 26 - 

thm oouBM of tttim stuV ooonittM tnoawzad aonasm tmstg the 
providers of long-^bem cart ednnatore and practiticne» in aany 
allied health fields are both uwilling and innpraparad for vark %dth 
•Iderly patients and chronic conditions. Itaaxks lUoe the fc^owing 
vera oftan heard: "R^Bioal therapists would rather work in qports 
■edicina and with the acute fhasa of trauna rehahilitaticn than with 
ftail, oonfused, noising ham patients." Long-tam care facilities in 
acne ragione are not peroeivad as giving hig^ qiiality, or evoi 
adequate care. Clearly a long-^tara, aajor effort is naedad to change 
perciptic n s of woock in the chronic care sector. Ihe figures in Tttble 
6.5 suggast that for dietitians working part tiae, and for full- and 
part-tiaa ooc»qpational and phyaioal therapists, ooqpaneatian is not 
likely to be a decisiva factor in choosing betuaen anploynent in a 
nursing and personal care facility and aaploynent in a hospital. Job 
satisfaction, houevar, aaty be greater in acuta cara aettinga. 

ICM«r-laval personnel— nirsing aides and orderliee— have fewer 
cfportunitiee in the acute oara eector. But, for thaee individuala the 
average hourly aalary of $5.15 for nursing aides in nursing and i .-sonal 
care facilitiee aig^ not be ocapetitive with altenativa aploymaTt in 
auch places as fast-food restaurants which pay acre and for which no 
fbmal post-secondary education is needed and working oonditiom are 
leas streesfUl (Rarachnar, 1987) . 

Long^^tflcn oara aaployara can try to utilize soaie ot the options 
suggested in the aarllpr eection for rural health oiplcyerB. 
Establidiing links vitti allied health education p r o gi aum to increase 
curricula content relating to long-term care could help deflect ecma 
andeties about aerving these apecial populations. Siailarly providing 
clinical sites for students can dispel nisoonoqitions about the work, 
enhance ekills needed to eerve in longrtem care and eetablidi ties with 
an anplayar. 

An Institute of Madicine connittee in 1983 that 
education p t uyianm for nursing should provide nore fomal instruction 
and clinical eoqwriance in geriatrics. It was believed that this would 
augment the siqpply of nev nurses interested in caring for Xhb elderly 
(Institute of Madicine, 1983) . For allied health practitionera too, 
this could ba an affective strategy, and is further ^<«^i ffff fHl in 
Chapter 8. 

Oandusion and Reoonaandations 

Maan resources planning has not been a hi^ priority nor an 
integral pert of strategic planning in the health cara arginization. 
Because of this there has been little enihasis on or invastaant in 
raeearch and es^erinentation in strucbiring staffing pdlicieo and 
«pocking environnents. Moreover, when there is a plentiful aaifjower 



- 27 - 

HMSE 6.5: Awnge Hourly EaznixigB in Hoqpltals and Nursing and 
FBTMnal cars Facilitiw, 1985 



MUraixig and Pentonal 
cara Facdlity 


9 11»92 

9 10.69 










Ilaad NUZB6 
















Head NUxse 




SOURCE: Buraau of Lrbor Statistics, Ir Justzy Nage Surveys, 1985. 



- 28 - 

Kqpply than is little inoantlvB to undftrtaka such an onarous task. 
Hanmnr, tha ooodttse fbvaaeas that th« availability of alternative 
anploynnt and stable or falling enroLucnts in allied health education 
p togi ai B S will find sons flnplcyars— fartiaU^iy hoqpitals— wprcpazed to 
solve difficulties in staffing and fulfilling seivioe dananLs. Relyjjig cn 
the yuw e iiBsiiL to czeate incentives, such as sducation siihsldies for entxy 
into prafeesiois that turn out to be poor careers, and oowplaining about 
lioansing barriers are not likely to be as effective a solution as an 
investaant in ijptoved sanagnent capcdsility. fieospt in the tax of 
aRxracidbly louer operating sargins, it %iill be difficult for 
atteinistrators to aaka e convincing oase for increaaed raiMurssBsnt 
(tiiroug^ the prospective paynent aystaai (FPS) , for exanple) to help 
sinxxrt salary incraasas tdthout having danons ti ated to payers that 
mnmjHwmt solutions hive bem pursued to tiieir pcactioal limits, lb date 
eaployers havo^ relied on naw graduates and ahort-tem incentives to offset 
turnover and prolong tenxre in the w ut kf o i oe. 

Ihe ooBBiittee raoonnends: 

BirlfffflTTf tfinulfl strive to irmnfif thf suddIv of alHori >^}tt\ 
tnaetitlcneM by Kt*nf*Anff parylft into health and Drolenalw;! their 

nnrt ertimtlonal asportunitieB. Biplovers also chould look to 

cools that include wen^ idnaritiea. caraer ehangers. and individuals with 

hnnrtinnmim oendifclenp. 

HoMBver, attracting and keeping individuals in allied health is only 
one pert of a strategy to relieve pressures. Ihe ocnnittee reocnnands: 

ghiftf aMwniUxm ^^<^Trff. tlllimn mmirpn dlractoTB. arA m-ho^ twM.i<-h 
eanft iirtm<n<«n^^^ ftflTftJld develcp methods of eff ective utillartiien of the 
«f1»rt-im iir^ly nin^ ho»n-t^ iyr..:onnta. Such methods Bust orcw cut of 
mmerlmfflTtation with new %ibvb of ^ficlentlv oraanlzlna the work and 
distriiJUtina Inhor immnr skill levels tfeile ensuri ng that quality of caara 
is not aamFanified. 

As ttm health industry looks more aggressively beyond cost-savings 
through reduced hospital utilization toward technology nimrinmiMiiil , qMality 
assurance, and nonhoepital utilization controls, it is apprcpriate that 
allied health services ccme under sczutiny* This ihculd be viewed by 
nanagenent as an opportunity to vork with allied health to use a scarce 
labor resource effectively. It is also an opportunity for alliad health 
to help provide the iMHuiilt underpinning that will be the f ounaation for 

The oonnittee zeocBnends: 

Hmlth onrn mnviderB and admlnlstratoBB ahould aaric Innovative vwva 
to Aarmel limited alH^ri hAAH-h inPBouroes to ac tivities of proven benefit 
to QonsumerB. Agencies such as the National Center f«r Wt^-\xh ^Pfim 

ErJc 25S 

' 29 ' 

^ Inmr ItWlWWmiBnt to «isur> that aUled health 

dnatino xmmoarA flrrfltuM Mrf pmiH><4i^ ^^Iml nfffflfffamoe 

and aqplzttticra of 
in tha wockplaot, 

If «|>loy«n an to UM linitad bagan laaouxoas in an af ftetive 

ba apprqpriately aduoatad. m adUiticn, the goals 
gtaduotaa ihould aoooed vith the vaalitias of life 
^1 their job aatisfactlon is liJoely to ba 
t h ar efq .^ strongly l a ujim e itto tha fbllowing: 

<n n«TBftnii7t.iVl mrtmpg— "h"^: the cacncmiar oe of «plotfinent and 
HHmntiiflli '1^— aairiuin.^. lAHrh ■hnn^ ^^^^ft p|ac3e at the state and 
local laval. ba anhanoad by the partle4n.*i-4en nf »A^^mrg ^ 

Although ttm analyses in this study axe nost often based on national 
data, Mm ooBsiittaa aiishasizes that conditions differ anong states, and 
mmt mans looalitias. State legislators have a legitimate interest in 
aaniring an adequate sqpply of health care pereomel, educational 
opportunitias for ttm states' citizens, and oqploynent opportunities for 
graduates of state aifiported education programs. Ihe ocnnittee reoonn»v3s 

^^^»^m^\yf, fr^jftp ftfyyild establlitfi ffprlfll r anmittees or 
of standing ocradttaes \t)oeti prlimrv purpose w ould be to 
fftrtff finfl iTOl iffmWff In the edueatlm and anm lownent of all ied 



- 30 - 


AUom, L. 1982. Ihe Haacm labor ItorkBt. Health Affairs. Vol. 1, no. 4: 
30-40. dted In Buerhass, 1987. 

Mkm, L. H. , and C. F. Millixnax. 1987. lha NUxse Shortage. )^ or 
Reality? Spacial R^xirt Nav Bnglanl Journal of Medicine, Vol.317, 
No. 10:641-645. SqptMber 3, 1987. 

Anarican Heapital AMociation. 1986. Report on Vrdan Activity in the 

Health care mdbstzy. D^ m Uaa! ', of Hunen RBsouroes, American Ho^ital 
Aaaociaticn. Chicago, 111. Septodaer. 

Araujo, M. 1980. Gnaative nursing aAninistraticn sets cliaBte for 
retanticn. Hospitals, May l, 1980. 

Bairiaerg, R. 1981. Bduoating Clinical labaratory Scientists in the 
1980s: Sena Suggestions. Anarioan Journal of Medical Technolcgy, 
Vol. 47, Mo. 4(A3rll):259-261. 

Barr, J. T. 1987. Ihe Nav Age labaratory: Ihere is More to Clinical 

labaratory Scianoe lhan Doing the Tast. Uhpublidied pc^. College of 
Riaraacy and Allied Health Frofc ^ions. Nartheaetem Ukiiversity. 
Boston, Mass. 

Hlayney, K. D. 1982. Ite Moltiple ODn|»tency Allied Health Technician. 
Bditaral. Ihe Alabama Journal of Medical Sciences, vol. 19, 
No. 1:13-14. 

Blayney, K.D. 1981. Ihe Alabama Linkage Story. In Sharing Resources in 
Allied Health Education. Stephen N. Oolliar, Bd. Atlanta, Ga.: 
Southern I gional Education Board. 

Buerhaus, P. I. 1987. Not Jomr Another Nursing Shortage. NUrsiiig 
Eoononics, Vol. 5, No. 6 (IHav-Dec): 267-279. 

Cooper, F. R. 1982. A Survey of Graduatar of the Iftiiversity of Alabama in 
BizBinc^iam School of OonBunity and Allied Health Junior OoUege/ 
Regional rcachnical institute Linkage. Sctoo] of Rdolic Health, 
ttpubliflhad paper, ttiiversity of JOidbama, Biminglham. 

Oordes, s. M. , and J. 8. Nri^. 1985. Rural Health Care: Oonoenw for 
I^esent and Future. In Raviev of Allied Health Education, Second 
Edition. Joseph Haaburg. Laxington: Uiiversity Press of Kentudty. 

Eiaenberg, J. m. 1982. The Use of Ancillary Services: A Rale for Utili- 
xation Reviev. Medical care. Vol. 20, yj, 8(August) :849-860. 

Garg, M. L. et al. 1985. A Nev Methodology for Ancillary Services 
Raviev. Medical Care, Vol. 23. No. 6 (JUne): 809-615. 

Health Professions Report. 1987. Federal Policy on Nursing Shortages 



- 31 - 

Health Ftofassicni Mpoct. Vbl. 16, No. 23:2. i -vmter 16. 

Health rnmurr— and Samdoes Ateinistratlon. 1987. Rural Hospitals/Hac 1th 
Sttvioas. Opulali^Md. fieacutiva Stagaary. Offioa of the Adninistrator. 

Haracn, S. L., J. K. Ifeu±in, and S. A. a\>ch. 1:^7. Ecxnonic Sector and Job 
Satisfoctlcn. Italic and Ooofiation, May 2, 1987. Vol. 14, Mo. 2: 

mtltube of Medicine. 1983. Rning and NUraing Bducaticn; Public 
PoOLicles and ndvat* Actions. Itoihington, D.C.; National Acadeny 

Karadmsr, P. ^ ^7. Staffing: Getting the Edge sn NcOonald's and Pizza 
Hot. FKovider. AFr;i:39. 

Ritdwr, R. E., and J. A. MBkik. 1983. Ihe sezvios-producing aector: sane 
ocmcn peroaptionB zwiaued. Monthly labor Rsviaw (April) : 21-24. 

link, C. , and Settle, R. 1980. Wage moentives and Married ^^fessicnal 
MUraes: A Caae of BBcSQuard-Bending Simply? Ecncntic Unguizy, Vol. 19, 
No. 1: 144-IL: 

I0V, G., ani A. Heiabord. 1987. Ihe Maltioon{)etent X%actiticner: A Needs 
Analysis in an llrban Area. Journal of Allied Health (February) :29-39. 

lunzer, F. 1987. m Health Care, A Move to Ufiicns. Hashington Post, A 
Medcly Journal of Medicine. Health Science and Society, JUne 16:10-11. 

Mansfield, C. J. 1987. Hnan Rasouroe Managonent in Hospital AMnis- 
tratlon. Journal of Health and Hunan Rwouroes Administration 
(Winter): 355-368. 

MeUcr, E. F. 1987. Neddy earnings in 1986: a look at acre than 200 
ooc.>jpaticns. Monthly labor Review (Jtine) : 41-46. 

Mitchell, C. Wall Street Journal. Septeoiaer 14, 1987. A Growing Shortage 
of Skilled craftnen Tktxdales Scne Finnw. 

I. 'se, J. L. and C.W. lAieller. 1981. Koijs&lcnal Turnover: The Case of 
Mirses. Janalca N.Y.: Spectrum Fublicetticfis. 

Reagan, B. B. '1986. Z^ifferenoes in 1982 mouoe of Foobile and Male 
Riysical iherapists. Rnpared for the Anerican Rr Iher^ 
Ass x^iaticn. UiubliriiBd paper. 

Reiiterdt, U. E. 1987. Scater Qouds on the Horizon, r^ltli Week. 
Vol. 1., No. lO(Deoaii3er)23:6. 

Kytim, N. ?. 19P'*. Earnings cf aan and xnen: a look at qiecfic oocu- 
paticns. Mom ^ y labor Rr/lew (April) : 25-31. 

Shelled/, D. C. , and S. P. NiJdes. Staff burnout among reqpiratory care 
-sarsonnel. Reepiratccy Managonant (Marctv'^'liz-il): 45-52. 


- 32 - 

airoedar, S. A. 1987. Sti»tagl« far Muclng HkUobI GDsts hy Oianglm 

S!!if^JS*':?S^J*^^ apact on Quality of c£*7tot«L- 
tlcnal Joonal of TKhnology fummmrtt in liMdth (to. 3:39-50. 

Itowiltolth ttLWB. 1987. FublicBtions dMcriblng activitlas ttm Texas 
Hospital AnociaUon, Austin, Tmaa, 

^^^S^JIlLII^L*"* SiPt«*»: 27, 1987. America's invisible Amy 

w linn w II KMi ii» ' 

"86. Hational Surv^ of Hoepital 

'**^^?i!H',i; £;<i!?^;J5?ff!L!?*^*°^ BiplO!y«:/B4ioBtor survey. 
American Madioal MnologlBts Events (MayOtna) ;75-78. 

tteisBn, C. S. et al. 1981. Determinants of Hospital Staff TMmJwt, 
Hadical care, Vol. 19, Nb. 4:431-443. 



Chapter 7 


Ths cxaTgressicnal charge to this oonnittee diracts it to "investigate 
ouzrsit practlcses under %ftiidi each type of allied health peracrmel dstains 
Homes, cscedentlale, and acxsedi.caticn'* (Sectim 223(b) (3)) . Die 
oonnittee has taken a rather broad view of this charge, interpreting it to 
ba directed toward the oonoem of ODngress and society for tha whole array 
of ■adianiaBB naant to assure that allied health perBomel aia properly 
trainad and ooopetent to practioe. Ihese nachanians, vhich cncxnpass 
lloensure and other fanas of gcvemnental regulaticn,. voluntary 
oertifioation, and standards iaposed by health care prcviders and payers, 
ere central to this study in that they interact with and influence 
virtually all the other stud/ issues. 

For mBBo^e, the scope of practice defined under state licensing 
statutee and regulations affects the daand for allied health personnel by 
oonstraining how they vey be utilized by oployers. Oertificatiori, if 
accepted as a valid distinction by enployers or if zjqjired by accrediting 
bodies such as Joint Oonmission on Jtoc r sditation of Healthcare 
Organisations (JCMC) , also affects anployers' desisiorai to enploy allied 
health personnel; certified and non-certified negobers of the same allied 
health field then are treated as separate labor pools. Regulatory 
Bechanians edso influenoe siQjply by defining «ho nay enter, nnd renain in, 
certain allied liealth fields. 

A great deal is at stake here. Health care payers rely on licensure 
and other cxedentialing aechanians to assist than in defining eligibility 
for coverage and rRlwhnrwront for the services of allied heal^^h 
personnel. The various allied health occupations look to the&e mechanisns 
to give than idmtity and legitimacy by defining the nature and length of 
training, other zeguirenents tor entry to the field, and the power to 
control certain health care practices. 

Xn a tixBB of great ferment in health care, these con tr ol aechanisBs 
take on evx>n greater significance. Ihe proliferation of health occupa- 
tions, changing nodels of health care delivery, and new reiiisursenent, aloirKr with cost-oontrol efforts by industry ard governnent, place 
stresses on these controls. 


- 2 - 

In carrying out this part of the ocngressioned charge, the ccD&ittee 
has held discussions with officials of govemnent agencies and private 
arganizaticns re^xxisible for the various control nachanisas. It also 
hald a public hearing at lAiich testinon/ was heard ttm 26 allied health 
attsociations and four other eccperts, two of when pcepared papers for the 
ocnnittee on state regulation of health ocopations. iOso, the oonmittee 
reviewed the iwj <> nn :lt literature on occqpotional regulation. 

9iethods of Oontrol 

State regulatiiii 

Sociflfty applies oamy quality ocntrd aethads to health care 
personnel, includUng allied health personnel. Ohe states bear the greater 
responsibility in this. Sirouc^ ooopational licensure and other fonis of 
regulation, states exercise their authority to protect the health, saiety, 
and welfare of their citizens. Ohe earliest nttcnpts to regulate health 
occqpations in this country were in colonial Virginia (1639) , 
Massachusetts (1643), and New York (1665) , when medical practice acts were 
enacted. By the turn of the century, the Siprane court had validated this 
use of the states' police powers and nost states had licmsed lawyers, 
dentists, pi^macists, physicians, and teachers. Between 1900 tjid 1919, 
acoocding to a bacJogrouncI pe^ prepared for this ooKnittee, nurses, 
optometrists, osteopaths, podiatrists, and veterinarians also were 
licensed in oost states (Ctapenter, 1987) . Before i960 this list had 
expanded to include dental hygienists, practical nurses, an3 physical 
therw>istSv Since 1960, only three health oociQations hv/e cone to be 
universally licensed: psychology, nursing hone administration, and 
anergency medical technology. n» latter two are liceraed as the result 
of federal legislation. 

Table 7.1 shows the licensure status of the 10 allied health fields 
on iitoidi this study has concentrated. Among these fields, i*iysical 
therapists and dental hygienists are licensed in every state. Dnergency 
medical technicians mst be certified by jam agency in every state. At 
the other eoctreme is the field of medical records adtadnistration, in whi.n 
no state requires licensure; this field relies irateid on certification 
(registration) hy the American Medical Recatds Association. All the other 
fields are licensed in some states: respiratory therapists in as few as 
•even states, audidogists and e^eech-lenguage pathologists in 

Licensure is the most restrictive form of state regulation. 
Carpenter tl987) defines licensure as "a process by %hich a goversmental 
agency restricts entry Into an ocapation by defining a set of functions 
and activities uanstituting a 'scope of practice', grants permission to 
engage in that practice only to persons meeting predetomined 



qoalif ications, and ^wtabliahes structuiBS and prooeduxBS for scaDeening 
applicants and granting lioenfies to practioa." These and other 
d&finiticm ahaxe cse: sir caman elanents, including: 

o liumsuTB is intended to protect the public 

o lioenp jg a is exclusionary 

o lioei»2re prascribes the characteristics and qjalif icaticrs of 
person s who nay be licensed 

o lioersure definas a ccope of practice for licensees (and 
t^Jerefo^a lioansura laws are often referred to as "^practice 

o licensuxe porohibits non-licensed persons fktam engaging in the 
defined scope of practice. 

Altfacuglh the standard definitions focus on initial entry, licensure 
also adUresses standards of practice and ethical and business behavior 
(%tat it taloBS to Iceep a license) , and on causes for disciplinary action 
(lyhat it takes to lose a license) • 

By long tradition, licensure has been, for all practical purposes, a 
form of state-qponsored self-regulation, since it has been carried cut by 
boards nrrrrnnl of nenberr of the regulated occtp^tion enpcwered to act 
vitii a hi^ degree autoncny. As Shixdberg (1984) noted in recounting 
the history of state licensure: 

These boards had broad powers to inplenent the law 
by proDDulgating rules and regulations governing 
practioa standards and professional conduct; 
establi^iing ift^n^imim edtjcation, training, and 
experience qualifications; examining cardidates as to 
their fitness to practice; investigating ccnplaints 
agaiist practitioners; and taking appropriate 
disciplinary action, liduding suspension or revocation 
of a praOdtioner's license inhere appropriate. 

Recent ref oms have broadened the nenbership to include 
representatives of the piblic ite> oay or nay not have voting privileges. 
But, on the %tx>le, the 1 sensed occqpatiora still are largely 
self-regulated. This point is elaborated below in the discussion of 
problens and recent refoms. However, licensure carries %dth it a ^^le 
array of regulations and administrative procedures for iaplenenting the 
state statutes. 

- 4 - 

T9SBLE 7.1: LioenMM Status of Salectad Allied Health Fields 



Clinical Laboratory 

Dental Hygiene 


Bnergency Medical 

Modical Record 

Ooofsaticnal Therapy 

Fhysiced Therapy 


RB^iratcry Therapy 


Maiical technologists are lics^sd in 5 states 
and Nev York City. Tachnicians are not licensed 
in any state. 

Dental liygienists a^ lioensed in all states and 
the District of Oolfjobia. Dental assistants are 
not licensed in any state. 

Dieticians are licensed in 14 states, the 
District of Coliinbia, and Rierto Rico 

Oertif iad in all states 

neither medical record administrators nor 
TOdical record tedmicians are lioensed by any 

Ooci^tional therapists are licensed in 34 
states, the District of OolnDbia, and Rierto 
Rico. Occif>ational thera^ assistants ai.^e not 
regulated by any state. 

Riysical tlierapists are lioensed in all states. 
R^ical then^ assistants are licensed in ir 

Radiogreqphers are licensed in 17 states and 
Rierto Rico. Radiation therapy technologists 
a^e licensed in 15 states and Rierto Rico, 
nuclear medicine technologists dre lioenssed in 
10 states and Rierto Rioo. 

RBGpixatoiy tfaexsqpists are licensed in 7 states. 

Qp oo c h -language pathologists and audiologists 
are lioansed in 36 states and Rierto Rioo. 

SOURCE: WSStHMS:} E. J. St al. 1987. Allied Health Progressions in the 
united States: A Smnary of Origins, Developnent and Potential 
nitures of a Selected Sanple of Allied Health Fields. Badqnxind 
pKger pnpaxed for tlie Institute of Medicine Oonnittee to Study the 
Role of All Perscmel. Itatitnony of acne allied health professional 
organizations, presented to the oomittee during a public neeting. 
July, 1987 


Ststes can and do crqplcy a runber of nodes of oocqatlonal regulation 
ether than lioenBure. A taxonony of the different nodes appears as IU>le 
7.2. Aarang our 10 fields, title protection throug(h registration or 
certification by the st&te is the most frequently coployed form of 
regulation other than licensure. This regulatory nechanisn is also 
aqpplied in ether fields such as aooountancy, v4iere anyone can practice in 
the field but only those ^ have net state standards can use the title 
•^certified Mblic Accountan'c.** m one form or another, about BOO 
oocipations are regulated by the states, indodi*:? architects, real estate 
farokerB, barbers and ooGnetblogists, electricians, and engineers. 

Beside ooor^onal regulation, states also regulate allied health 
personnel through the regulation of institutions and settings %ft)ere they 
work. Ihe reguirenents for licensure of hc^itals and nursing hones 
include standards for per so nnels States have other laws and regulations 
of brond applicability in j^aoe, such as those that govern business 
practices and prcvide consuner protection, %dhich nay be used against 
inocqpetent or unscrupulous allied health personnel. The states also 
define qualificatiora for civil service positions neld by these personnel. 

Qonsuners vbby utilize the tort syston in ary state to file civil 
suits to seek ccnpensation for nalpractice by allied health personnel. 
Fkesunably this nachanisn carries scne deterrent effect; hoMver, in the 
oonteoet of quality assurance it oust be viewed as a last resort. 

crittclsnis o f fitut^ rBoulation Oocipational regulation has been in 
fement for at least 20 years. Qdticisns have cone fkan a nunber of 
quarters, and these criticisns have given rise to recamendations for 
refom. Sone changes have taken place as a consequence. 

In the 1960s, the source of conoem was health care access. With an 
qpparent dxsrtage of physicians, there vas ccncerr^ that restrictive 
licensing laws were hanpering the effective deployw^ and utilizaticn of 
pbysiciwi assistants and other physician extenders. This issue was 
addressed by the National Adsdsory Oonnission on Health Manpower in its 
1967 report. At the direction of congress in the Health Itaining 
Inprovanent Act of 1970, the Department of Health, Education, and Wielfare 
investigated problcns in licensure and certification of health personnel. 
Ihe Department's 1971 Report on licensure and Delated Health Personnel 
Ckedentialing contained f^reaching reccmnandations, including a 
reocBuendation to the states for **a twoyear noratorium on the enacta^nt 
of legislation that would establish new categories of health personnel 
with statutorily-defined scopes of functions.** The moratoriini was to 
allow tine for further consideration of the tasks and functions of new 
health ooaqpations. 


- 6 - 

TAILS 7.2: Nodtt of Occupitlonal ttfvlttfon 

1. ££i£iiajLiQdtf:di 

without wo^imi ■nfowi^^ 

Ihrm^ tht adoptfon of ttitutio and rulos. this aodt t&r ootoblfsh mtrfctlont on tht 
praetlct of m occqMtfon iHth cfvfl or crfalntl pmltfot onforcf bio throi^ tho 
coMT ti, TM » ttypt of ro^lotfon rtqulrtt no Iniptctloni. rotfotrotlon or apocfol 
onforcMnt otoff. Kothw* ft rolfoo on action bf ttio honnd portloo or by o c«nMJ»r 
offoiro offlco. 

With oaecUl n^firfMllllt 

lliroi«»i itotutoo ond/or nilos. this aodt am ootibllih rob.trlctlQns on tho pr^rtlco of on 
oco4»tlon In addition to ootabllshing Intpoctlon. onforcMnt Mchonlw «id ponoltfoo. 
Uonm^or, thii flDdt dooo not roqjiro rogfotrotlon. cortlf Icatlon. or mxf oosotOMnt of tho 
praetltlonor'i crodwtloU or coipttoncy. 

2. Koflfotrotion 

trtthout ttirkrA 

Through rofulotlon. o ototo igincy em roqufro poroono In on occ^^Mtfon to rtgfotor mJ 
OMpply cortofn InfofMtlon nfthout roqufrfng ony otondardi. tottfr« or onforeoicnt. 

With «tidirA 

It lo olso pooofblo to h«« 0 rogfotrotlon roqufrowit In oodifnitfon iifth afnlM 
proctico otondordi oot by o dttf^wtoi ogtncy. vhllo rogfotrotlon Mould not bo 
oxcluilonory. It nould M^joct row*ol:ronto to Minfu ottfidordo ond thoroby provfdo tone 
protoctfon to tho public. 

3. Statutory Oft^f^l^|^^gp 

With itato atandardi and «f f ^trf^e^t 

ThroMah ro^ilotlon. oec^»tlonal Mtert can bo roqjfrod to naot cortofn atato atandarda; 
only thoao lAo Mot thaao pradatonafnad qualff icatfoni My lagally uat tho daafgnatad 
tftlo of tho occi^tfon. Thia aoda antaf la atandardi, taatfr«. codtt of practfco. 
pooafblo fnapactfona^ and anforcoMnt. 

tfftt) PTfvitt atondar^ and aaaat—nt and ^tmtm 

Throi«h ra^latfon. an aganey of tho atato aay roqufro Mbora of m occKtatloral 0roi4> to 
Mot eortoln atandardi oatabllahad by a privato tooting or oaaaaMnt cantor or 
organliatlon (rovloMad by tho atata). ulth tha atato h«lllf« tho cortlf fcatfon «id mtf 
onforcoMnt ro^Jlrod. Logalty. tha atato la raaponalblo for tho atandardi aot and f or 
■onftorfng tha proooaa. 



- 7 - 

TAHE 7.1, coitfiMd: Nodtt of Oecupatlonil Kt^ulttion 

4. tutorv CtrtHleatlcn id Pr^t\cm ttandirdi 

A ttatt My wtibllth by rult ctrtffleatfon for an oco^patlon and uino roquest tht 
loglstotyrt to past a Ian liiich Mould attabtlah praetica atandardi for that aaw 
occupation. Ihia canblnatlon tmild aatabtlah a ayataa of tlt(a control for tfioaa atatfno 
cartain raqjirad atandardi of co^pttancy, aa mii as aatibtfahfno atvidardt of practica 
for anyona Mho practlcaa tha oc c tyatlon* 

5. ttflulaticn th -ourti iicarvfaffln bv an Alraad/ Hctnaad »ractltlonar 

CarHf teatton Mith atandardi 

Ihrough atatuta and rula, an oco^tlon can faa cartfflad and raqufrad to Mork -ndrr t^ia 
ai^rvlalon of an alraady ilcanaad oco^tfon; atandardi for practica can alao ba 

Through atandirda of practica but without cartif Ication 

It la alao poaalbla to ragulata bf providing that tha oco^iatlon ba perforwd indar tha 
ai^rvlalon a Ilcanaad profaaslon Mith cartain atandardi aat forth but without 
rac^lrlng that tha Individual ba cartlflao. 

6. Licanaura 

LIcanaura tapraaanta tha noat raatrlctlvt fom of ocoi^tlonal ragulatlon providing for 
both tltla control and an axclualva araa of practica. It raqjiraa atandardi of practica, 
oducatlon. knoMladiiO and/or alnlM 0Qapatancy« Intpactlon and ariforcawint Mith civil and 
crinlnal panaltlaa. 

SOURCE: Sybil K. fioldMn and W. David Malaa^ "Tha Kagutatlon of tha Naatth Profaaalona." A policy 
ravloM praparad for tha Coaailaalon of Naatth Kagulatory ioardt of tha Coannnuaalth of 
Virginia. Octobar 1965. 


- 8 - 

QuestionB about the wiadon of ocaqpational licensure have pexBisted 
to the piresent, althouc^ cLxcumstanoes axe different. The peroeived 
dwrtage of docton and dentists has dianged to a percseived surplus, and 
Ite TU^bBC of neulymaergirq health oooqpations is incraasing. Since the 
early 1970b, the issue of rising health care costs has taken on greater 
and greater isportanoe. Jn the context of cost ccnta.jfinent, the fact that 
■ore and aare health oooupetticns have been seeildng statutorily protected 
scopes of practice is %X3criscne. This proliferation is seen as 
contributing to inefficiencies in the health care indust y, especially so 
in view of the rapidity of technological chui^e. 

Allied health personnel are affected by ttiim tension. Many of these 
fields ar^ nsv, and, acoocdlng to the exaqple offered by older, 
Viell-«sta!3liihed fields such as aadicine, nursing, and dentistzy, state 
licensure is czucial to thair achieving recognition as professions, 
licensure, it is believed, gives legal validation to the field's unique 
status. It provides a wiy of eaocluding imqualified pcactitionezs frcn 
providing sezvicas, it gives official reooTiition to tbb field's scope of 
practice, and it offers easily verified .credentials that can be used by 
flBoployers and health care payers (McXkeady, 1982) . licensure also is 
considered neoessary to awoid being subject to prosecution for practicing 
nedicine without a license, since many nedical practice acts are so broad 
that physicians are granted virtually unlimited scopes of practioe. 

Above all, state regulation is viewed as a means of infiroving the 
quality of health care by restricting entz^ to persons tAx> have proper 
ccedentials and by disciplining persons yitxt do not meet standards of 
professional behavior. Much of the criticism leveled at regulation is 
baseii on th<^ lacdc of evidenoe on tiiis point. 

gHt-IHgnw as to stnicture and ppooess The traditional regulatory 
structures and processes, developed in the last century, are criticised as 
anachjTonistic and inconsistent with their central public policy 

Ey long tradi t i on , the regulation of a health ocopation, given a 
practicr statute, is the zeeponsibility of a board. Ihe conpositicn of 
the board is usually defined in the statute. One of the s ti uigwsL 
criticiflns of the vegolatory structure is that these boards are not 
sufficiently accountable to 'ens larger public, until recently, they were 
OTTrnRflrl entirely of mentacs of the regiilated occupation, drawn frcn the 
■ eni jeinh ip of their related asr%iaticns. In many states they generated 
their own revenues by charging fees to candidates and liceraees; they had 
their own staffs; they often were located in the hone of the boioA 
secretary; they had considerable rulenaking authority %fith little or no 
oversic^ht. Oheir proceedings voce closed to the public, as vere their 



statute, the z«gulatoxy boards are diazged with setting entzy 
zeguixenents; vith setting practice stanSazds and codes of conduct; and 
vith discijplining licensees «ho fail to aaet those standards and codes. 
The petfomnae of ttmae functions also has been subject to criticism. 

Eligibility standards are defined in terns of edocaticn and, in sane 
cases, eaqpericanoe. Boards also reqoire entrants to pass an eKamination. 
The exam in scne oases is devised b/ the board. In others, the board 
relies on a national eocamination or oonnissions a tasting organization to 
develop a state exam. Criticisas leveled at entry requdranents are that 
they are inflexible, offering only one path to entry; that education and 
eaqperienoe requirements are unrelated to the denands of practice; that 
educational rei]LdragKnts rest heavily on accreditation, %ftdch in turn is 
controlled by the professional associations; that examinations are not 
valid reflections of real-world practice rec|Liirsnents; and that the caancn 
practice of "grandfathering" current practitioners \ten licensing a new 
ocoQiation is inooraistent with the goal protecting the public health and 

"Standards of pcactice" are defined in terns of behaviors that are 
subject to disciplinary action, including fraud and deception in obtaining 
tte license; conviction of a felony; engaging in unacceptable patient care 
through deliberate or negligent acts; knowing violation of the practice 
act; oontiiuing to practice although unfit; and lewd or ianoral conduct in 
the delivery of services. "Codes of conduct" nost conacnly prohibit 
business practices that are considered unacoeptable professional 
behavior. Ikaditionally, these have included advertising; practice in 
chain or departnent stores, shopping centers, or other "comnercial" 
environnents; and engaging in ccnpetitive bidding. 

Disciplinary procedures are usually defined in the statute. In seme 
states and for some occupations, revocation of the license is the only 
sanction provided. In others, an array of sanctions of varying degree are 
provided for including license suspension, censure, and repriiDand. 

Boards have been criticised for the way they carry out their 
disciplinary responsibilities. Ihey only investigate ccnpltdnts of 
incoBFetenoe or ispropriety rather than doing any independent aonitoring. 
Sipt«priety (that is, violation of the code of ethics) is aore ftequently 
<Q)e basis for disciplinary action than is iixxnpetenoe. Ihe ninber of 
disciplinary actions is extremaly low in oaqparitson with estimates of the 
incidanoe ot inocnpetent practice. Ohe public is not informad cJ 
disciplinary actions against licensees. A partial o^ilanatlon for the 
historica? lade of disciplinary vigor is the Inadegoacy of resources 
available to tiie task of Investigating and "prosecuting" oonplalntfi. 
Withujt sufficimt staff and budget, as Shinfcerg has observed, the 
regulatory process is aore bark than bite. 


^^TsjorP' mitoring and turf ptDtacticn cxxxfy a signif iosnt pcortion of 
tte mmtqLm of a atata^s ragulatocy apparatw. Itm variow ooaqpaticra 
axa taatUlngr amom thanaalvaa aa to Oiicii piaoea of taMlth oara and lAiich 
piaoea of tte patlant thiy hava jurladictlon ovar. Iheea battlaa ara 
foug^ thiouc^ aatddlAing practloa acta and iaplcnenting zulaa aid 
ZBOulaticaro. It. > ia not tha only thaatar; iisuranoa oovanga and 
xalBburanent ia ancfthar. But tha regulatory arena ia %tera the identity 
and paiiter of allied haalth paracmel ia largely dateradned, 

Ih oarrying out ti)ft atud/ tha oooaittaa anocuntared nmy axanples of 
juriadictiorad atrugglaa aacng allied health and other ooaftttions, 
atxugglea that oause their roles to be oonstantly ehifting. Fbr imtanae, 

qphthalmic ndioal eaaiatanta versus optanetrista Gn perfondng 

aurgic^ tachnblogists versus nurses on vhD rimild perfom 
various tadcs in the cperating 

— OEtfatatists versus pliyBlcal thexapists on fitting taraoes and other 
orthotic caevioes 

— audiologists versus hearing aid disperaere in hearing testing. 

Ihese struggles, in vhidi oocxqpaticns se^ to eaqpand their realm of 
control at the oqpense of others, are a constant elcnent of regulating 
health ooaf)aticns thrcug(h licensure. In aany oases, the issue is %ftiich 
occupation is entitled to perfom specific functions. Ih others, the 
issue is %Aiich ocaqpation or oocipations have jucisdicticn over f-«> 
portion of the hunan anatony. In still others, tt» issue is uncler «hat 
ccnditions persons in tite oontation perfom their fUnctiom. Fbr 
exanple, in nany states physician referral is required fbr physical 
theraiy or ooofiatlonal therapy, but not for speech therapy. Another 
iaportant condition of practice is the level of siqpervision leguired. 
These referral and siciervision provisions in licemure statutes define the 
degree of autoncny of haalth care VDrkere on the one hand and tteir degree 
of availability to ocnsuoem on the other. Decisiom on tiiese by 
state legislotorB and regulatory bureaucracies affect tiie costs, quality, 
and aooessibility of health services in their states. 

Ihe great difficulty facing state decisiomadten is that the iapact 
on costs, quality, and acoessbility of any proposed aodification in a 
health oocqpation's seeps of practice, referral, or a^nvision is rarely 
dear. Vhe risks and benefits of change often are faypoQietisal, difficult 
to seasure, and subject to Isrge differences in judgpnent. Shetoric and 
political pcMer frequently substitute f jr evidenoe and rational decision- 
aaking. Rarely are there rigorously done studies. 


- n 

(km of Urn dMXWt •xwnrliw of this prdkAm is the case of dental 
tvgimm mnvixsem. In the ooutM of tMitinv IV nprasentatives of the 
AaerioBn Daital qyglMfdsts' Anodation and the taerican Dental 
Association at the ocanittae's July l, 1987 public hearing, oonnlttee 
aoeniian laaxned of the oontiniing oontxoversy over the required levels of 
siliervision of dental Ivsrianists fcy dentists. 

2h general, dental faygianists are only penBittad to practice (that 
is, perfocB a variety of chiefly preventive services such as cleaning 
teeth, taking x-rays, applying topical fluorldas, and teachin proper 
dental hygip^) under the sifiervislcn of a licmaed dentist. Ohe 
•vervision aay be •^general", vhich aaans that a dentist aay delegate a 
given finction. Ihe dentist wueit be re^nsible fbr its successful 
pert areanne but does not have to be physically tftitMJiil while the delegated 
function is carried out. Alternatively the supervision aay be "dizect**, 
leaning that the dentist aust be present in the same zoon as ute 
hyglenist, or "indirect", %hich regoires only that tte dentist be present 
in the U e a Latai t facility. 

Sit)ervision regoironents vary among the states. According to the 
American Dental Hygienists' Association, 38 states peznit doital 
litygienists to practice at least aome preventive oral health services uvier 
general siftervision. In some states, general supervision is United to 
hospitals, nuraing hones, adult day care centers, and other iistitutional 
settings. (American Dental Hygienists' Association, 1987a) In the state 
of Nashington, dental hygienists have practiced uisB^visad in long-'tem 
care facilities since 1984. 

Ihe Anerioen Dental Association is seddng to ti^jhten si^iervlsQxy 
raguirenents for hygienists. In 1986, tite ADA House of Delegates r^ocax^ a 
resolution opposing general siqpervisian and urs^ state dental societies 
to eliainfite it from state practice acts. Ihe sane resolutian urged that, 
in instances %here general sqpervision could not be mnved from the 
statute, that the regulations be changed to raqoire that: 

(a) any patient treated by a dental faygienist first beocae 
a *t»tient of record'* of a licensed Jentist; 

(b) dental liygiene services be given prior authorization by 
a dentist no more than 45 days before the services are 
presided; and 

(c) the dentii.t aseaaines the patient within a reasonable 
tine aftei tt» dental hygiene aarvicas are provided. 

Ihe justification for this resolution vas that general 
supervision endangers the dental health of the public. Its effect 
%iould be to increase dentists' oontzol of dental liygiene services. 




Slncaa the twolutien pasMd, sffarts have been aade In eetveral 
staites to delete grnerel aifiexvisicn. A bill to this sffect ws 
introdooed In Oomectioit In 1987. In Vbcbs, «here general nqpexvisicn 
has been pezaitted 2br over 30 yaaxs, the Boaxd of Dental EMminexs 
pcqpoaad niles thatt wodd zeqaixe direct sqpexvisicn of all dental 
hygiene fUneticnB. (Anerican Dental Hygienists' Association, 1987b) Ohe 
Virginia Dental Boazd, «hich had been on tiie verge of liberalizing 
supervision xsgoivenents, decided against siKh action. 

Other states are aoving to relax their siqpervision reqaireoents so 
that dental hygiera ssrvioas can be provided without the dentist's 
laical pnesenoe. I s jl sl a tio n having this effect has been proposed in 
Kitfsouri, Ohio, South Carblina, and Wisconsin. At the ext^nene on this 
ocntinun is Oblorado, «hich in 1986 became the first state to allow 
dental liygienists to provide aost of their basic function without 
sqpervision by a dentist. Other fimctions, designated *=Mf>ervised 
dental hygiene", regudre a dentist's sit)ervision. Diagnosis, txeatanent 
planning, and prescadption of tiierapeutic neasures oontinae to be the 
responsibility of dentists. Ohe statute iaposes disciplinary action for 
dental hygienists vho fail to refer patients to a doitist when the 
treataent needed is beyond their socpe of practice. A lawsuit xo 
overturn ttm statute failed, but is under eqppeal. 

m California, 15 dental hygienists are allowed to dean and 
eoosnine teeth without the sif)ervisiQn of dentists. Ohis d(siastr%ticn 
program is one of the sta t e epon o o it i l Health MaifXMer PUot firajects, 
under %hich reqioirenents of state practice acts nay be waiver^ fbr 
aoqperijRBnts with innovative BStfaods of health care delivery. Aooocding 
to the Office of Statewide Health Plaming and Developnent, the agmcy 
respo ns ible for the program, it "is c Jthorized to ^firove locally 
conceived and iapleoented daaam Ua tion projects to prepare and utilize 
health personnel for new or eoqpanded roles." (Office of Statewide 
Health Planning and Developnent, 1987) . 

Td qualify for the program the hygienists needed at least four 
years of clinical eoqpericnae, oertifioation in cardiopulmnary 
resuscitation, and qpecial training in instnamtation. They are 
providing services in offices and in other settinEis such as nursing 
hones. Sane nake house calls to people «ho are bedridden. Oheir case 
records are reviewed by a dentist. 

The California Dental Association sued to halt tiie prxjgram on the 
basis that it was a ttireat to public health and that the procedures 
fOllcMBd ly the state and by California State Uiiversity in improving 
and iiplcnenting the program %«re inadequate. In August 1987, JVdge 
RothMell B. Mason of the SacraDento Oounty Superior Court ruled agaiist 
the dental association. His opinion was that the program was coraistent 
with the legislature's intent to «>iable eoqieriiKntation with new kizxls 



- 13 - 

anS ocBA^iraticns of ^tlivny m^ttms and tkm need Tor eaoenptlons fran 
ttie healing arte practloe act to pandit mxti eoqparittBr.taticn, 
foaifiamia DMital Ageoeiatlm v. pt^f io^ «i> fifart-^ilft HMlth PlMniner 
and DBvaloment at al,, 1987) 

Jn neithar the GblGondo nor the Qdlfdcnia oaaee vara the 
9Jtetantiva iaeuw raablved; txnth onses, to date at least, have hirTed 
oi prooedural aatters. Ih neither cesa vara any data or XBsaaich 
finUnge laiaiieiitac,, to wKsort azgmmts aibcut riaks or bmefita. No 
avidenoe wea inaamtaiA en the iasue of %tiat dental liygi^nista' tudning 
iiduke and lAiat types of re^malbilitiea th^ are prepared for. No 
avidenoe %iaa faaaeiital m the issue a!i eoreasitdlity of sarvioas; k> 
avidenoe %ias pr e eei itcd m the costs of services, 

m its tastimv to this ccnadttae, the ittDerican Dental Association 
stated, ^'lim Anarioen Dental Akv^ociaticn baliavas that al\ arf. vnts of 
the public tf)0uld xaoeive the aane hi^ stendard of dental cei^ ^. 
AesGciaticn axp i a aa aJ its omoams about the great neponsibility placed 
on dental care providers lay the need to diagnoaa non-dental dlswfy^* 
that aanifast eynptons in thn south and the need to preside eerv.'oes to 
petients %fao are acveraly madioally ainjiiurig ed {Jknodcan Dental 

Hm coenittae questicnad the ADA epctesparjor. about cirounstances, 
such as in public schools, ^inerm ti»3rr; wu3.d Le benefit ftcn allowingi 
faygienists to provide pro[tiylactic aeirvicas to children %to had be^ 
axamined by u dentist but idthout the dentist present, lha ADA'S 
of Ificiel poaition is ttiat Jiis fom of delivary is not nooeptab' j 
(lOistituta of Hadicine, i987). 

The situation in dentistry is not unique. It illjstrates issues of 
ooal, ii^ality, and anoess to health services coDncn t^ aany health caru 
fields. She conniittee is conc e rned that such issues are faced in the 
courts, in state lagislaturu, and in regjulatory agencies neither u 
Lody of statistical ci'idenoa nor the irfocned judmnents c£ knowledgrble, 
C ^sintarastad partiaa. Nithouv such infooattoi, there L ccnrideracle 
risk tiiat decisionr vill be aade on purely politioal and ermrmir 

Qrltj.cims as to Outomc; In addition to structure^ and processes 
of state regulation, thr.^ hava been siibstantial criticiffls of the 
outowas in tanas of haal\h cere cost, qualily, and acoeaaibility. A 
bod/ cf research litaraiaxre generally calls into question vheLjer state 
rasolation as va knov it is serving the public, 'ihe literature ehows 
with sons consistency that costs (prices) of hiedth r^: jbs and 
products (eyeglasaee dentures) ere highsr in s^ataB vith n:^ stringent 
regulation :;negun, 2981; Gecasar, 1984). Ihcxura of health professionals 
are also highsr in states timt xostrict activitisb of their substitutes 
and auxiliarids. 


- 14 - 

Hi^^wr oonsmer prloM poMumably reduce aooess by keeping soae 
oonsuners out of the aaiket entirely. Ihere also is direct evidence 
that restrictlcns, for instance on practice setting, nay reduce the 
quantity of services pcoduced. Begun (1981) , for eaeBn|>le, found that 
optonetvrists practicing in chain outlets conducted acire eye exaiF^tions 
in ei day than optcnetrists in private offices. Mamy states prctiibit 
pFBCtioe in a chain. 

&Dpacts on quality of care are less dsar, largely because of the 
great difficulty in obtaining data with %ihich to assess quality. This 
is unfortunate, because quality is central ''o the policy- ddaate over the 
CKtent and nature of oocqpa t i cn al regulation. Ihe vai^« health 
occupations argue for instituting regulation, for changin^^ their scope 
of practice, and for liadting the scopes of other ocaqpaticra entirely 
on the grounds of quality of care. As H ^^ri^uant has cfaserved, 
referring to physicians, "In general, the pt^/ailing professional visv, 
naintained i:i large pert as a natte)* of ethics, is that quality of care 
is the profession's business alone, that there is only one soceptable 
standard, and that cost has nothing to do with t" (Havighurst, 19—) . 

As Begun points cut, in this context "qjality** is ill-defined: "it 
■ay r efer to the degree of reflect for the professional, the degr«e of 
ocmiunication or honanisn in the professionajL-dient relation, i-he 
technical sophi ^cation of the service, or the actual outcome of the 
service." (1981^ . Other passibilities include the professional''^ nuidaer 
of years of tr<dning, the degree of trust of the professional by the 
client, an? the degree of client satisfaction. 

HcweTer quality is measured, its r^atiorahif to regulation is 
e^lvocal. For exanple, studies by Mdurlsi (1974) and by Carroll and 
Gaston (1977) have suggested that quality is actually lower with greater 
regulation. On the other hand, Holen's 1977 stui^ of dentistry found 
that sore strincpant state licensing standards reduced the probability of 
adverse cutcomes. Gaumsr (1984) orry-liided frcn a review of the 
literature that state regul^ttion could not be duwn t> reduce the risk 
of heath care personnel naking mistakes or errors in julgnsnt, nor in 
general to ensure oonpetenoe. Begun (1981) showed that zestrictiora on 
optcnetric practice are associated with hi^ier quality, higher cost, and 
lown: accessibility. Ait quality was neasured in terns of duration of 
aye laminations aid tteix omrlexity, so the result might be 
ettributable to f««er "lew" qiility exams bi^ done rather than jhxb 
•*hi^n (]uality eoaons. 

criticiflos of tutocnes of state regulaticr. also are at its 
effect on geogra(Mc and career mobility, niere is coraiderable 
xesearch to suggest that state licensure, oepecially with limited 
reciprocity, limits gecxpnphic mobility of liceraed personnel. It also 
limits career mobility by prohibiting advar xment frcn one level to 
another anS by prohibiting occupational charge wiViiout adUitional 

Er|c 27 C 

•ducatican. Hbe dlff itxlty of tzmBferring canadits, and of obtaining 
canadit fbr skills aoqaixed en the job naans that ^initial caraer choices 
czeattt a pathway vhich oan be left only by '^xacing one or note steps 
badcwaxtJ and essentially starting fkon an entry level onoe more.** 
(Carpentei:, 19B7) 

aefonns of State Jteoulaticn Ttoenty years of criticism has led to a 
naaber of reocnnendations for raf omn of state regulaticn of health 
ooa^atiaw, and sobb al those have been iflid.emBnted. 

Cfiterjn for recMlati on: >*Siinrifiew Procaedupa In the face of a 
growing ru±er of oocupations seeking licensure and a growing 
about the cost-effectiveness of licensure, 13 states have soiig^ to 
bring a greater degree of raascn and due process to %tet had! been 
largely ad hoc and political. Nijmeota was the first state to enact 
sunrise legislation in Itm Mixraeota exanple, criteria fron the 

Council of State Govemnents, and princ^es emanating from the U.S. 
Department of Health, Bcf cation, and Welfare have been used as guides in 
these efforts. 

Ite oriteria generally have been similar. Kisically they consist 
of a set of guidelines to use in deciding ^dhether an occupation should 
be regulated, and a set for deciding the most appropriate fora of 

Oriteria for regulating an oocupation include e/idenoe of harm from 
unregulated pnicti e, evidence that the ocoqpation involves qpeciaJlzed 
tfdlls, and evidence that the public is not protected by other naans. 
More recmfitly, a criterion of oost-eff ectivenyss has been added by soroe 
states. Minnesota's statute and current regulations (see Appendix 6) is 
an exanple of these criteria. Ihe rules epexl out in some detail vhat 
oonstitutes evidence of harm, including the kinds of harm that are 
rucognixed and how to amronff the potential for harm, indxxling the 
extent cl danger inherent in the oociqpation's fOi*. JLom. 

lUmMGfLa's regulations also apprcpriately racogkiize the rather 
long list of **other means** for protecting the public: s(vervision by 
other practitioners, existence of state or federal laws governing 
devricee an:: substances, cnploynent in licensed facilities, existence of 
federal licensing or other regaircments, existence of civil service 
procedures, existence of national ortification procedures. 
Oonsideration of these other means not only guides the decision to 
regulate at all, but alec can guide the design of the appropriate 
regulatory machanism if one is needed. 

The cariteria for selecting the mode of regulation follow the 
principle of employing the least restrictive activities consistent viti 
public protection tfwuld be enployed (see Subdivisic 3 of the Minnesota 
statute) . The least regulatory mode is the strengt*^ ^ning of thL base 


- 16 

for civil acticn aniVar of criminal prohibitions. This is essentially a 
xelianoe cn the deterrent effect of potential civil actions or crisdnal 
penalties. Ihe Bost regulatory node is coopaticnal liceraure, vhich 
prohibits persons «ho do not neet the state standards fircn engaging in 
practioe. An interuediate node is the establishment of title protaction 
throug(h registration or certification. 

certification has been used for nany years in the field of 
aoocuntancy. Accountants are certified by the stat^ after naetingr 
certain eligibility criteria. Ihese criteria vary among the states, but 
all states reqaire passirg grades in each of four parts of tte uniform 
national eocamination glv«n by the American Institute of Oertif iod Fiiblic 
Aooountants. Seme states have education retjuirements. Some also 
raqaixe eoqperiencse in public accountancy. Oertifisd status allows an 
acccuntant to offer Irdependeeit judgment about an organization's 
"books," tb» value of its assets, etc. In general, large argzaiizatians 
have their financial aoocunts audited and evaluzited by OAs. A lender 
generally ze9iixes an audited statanent from a firm seeking a loan. Ihe 
Securities and Bochange Qonnission reqidzes an aaiited statanent before 
approving a stock offering. In these capacities, CEAs wield 
considerable influence, their e^<^ftttine is widely understood and 
xeepected, and they can conmand substantial salaries. 

On the other hand, a person can prepare a firm's irancial 
statements, prepare tax returns, and perform mor^t acrxxtnting functions 
without being certified. Iftiless a conpany want» to ixsrrow mcney or sell 
ihares to the public, it does not have to pay for the services of a 
CPA. itn individual tas^ayer is not required to have his tax return 
prepared by a CPA, Thus, there are lower-cost optlora available for a 
wide variety of acoounting services. Bnploying these lower-cost and 
presumably loMer-quality options is rot without risk; one might be fined 
by the IRS or have one's cciii»ny fail because of low quality acoountJjX' 

However, in this field, uonsuners are able to weic^ the risks and 
benefits and to choose among an array of providers, given the iiportanoe 
they place on certification, and given their financial coistraints. 

The cono^ of aoononic iapact is a relatively new oanaept in this 
arena. It makes eocplicit a concern that the inposition of regulation, 
whatever its benefits, carries with it certain costs to society. These 
include any insrMBeg in the costs a- .irices of services, iisuranoe 
preniini costs, costs of additional training, and the oasts cf operating 
the regulatory machanifln. Z^. some sta«-'w these latter costs are 
defrayed wholly or partly tluxugh liceiwing fees, and thus ar% "off the 
books" . HoweveTf in «r/aluating the regulatory burden, these are 
significant costs, irraqpective of how the/ are financed, ihere 
prxbedbly is merit in getttins then on t^ie books, even if fee revemes are 
netted against then, as a means of focusing attention on how much this 
activity is costing eaJMty, 



Hw •ooncnic isfoct requixonent is very useful. It oculd and 
itauld b8 expwnrtPri to be a taroader "envixonnenta}. Isiact'* stateoent, in 
order that other criteria such as aooess and qoality nic^t be 
inxaqpexatmA into the oans:uleraticxis. This %«uld encxurage allied 
heal \ ocxxqpations seeking state xegolation, other parties at interest, 
and ttiB states to sake as eaqplicit as passible the nature of the 
txade-offis isxler ccnsideraticn. 

aef OHBS of t he Bequlatorv Struc±urB ar ^ Brooess The criticisns 
enumerated above have led to calls datincr bad: to the late 1960s for 
chemge in structure and prooass. Ohese xecor joidaticns have been aimed 
at incxeasing the public aooountability, efficiency, and effectiveness 
of state regulatory boards. 

BnarJ gangggitlBn widening the nenbership of regulatoty boards 
has been cne of the most consistent xeccmnandationB made bsf caritics of 
state ootaupational regulation (for exancile, CHEW, 1977; Shixiaerg, 1980; 
Begun, 1980; Oohen, 1980) . As statsu 1:^ Tiidiy (1976. cited in Begun, 
1980, p. 94) , "Govemnents cannot continue to coqpect that coh e ren t 
public policy can be achieved by dealing with professional groups as if 
they ware the 'cuners' of their reepective technologies." Ihe need for 
•pctlic input has generally been associated with consumer involvcnent, 
that is, the inclusion of cne or more "lay" aeu ije r B of each licensure 
board. A nafcer of stat^ have taken this step. These nesiaerB 
generally axe consuners (auch of t'le ispetus for having then came fron 
the rmf'Y^ mw ae nt ) ; they may or may not have full menijerdup 
status— voting privileges, for exanple. 

Altheuglh infotnad ooneumers have a great deal to offer to the 
regulatory prooass, there is scne question as to whether adding one or 
two ,3nsuiner8 to a board of 8 or 10 inaisers of the regulated field, 
•specially if the consumers cannot vote, will have the "esixed effect of 
making the board nore accountable to the public. More xax^reaching 
zeooomandations to this end indtsde: 

— Drawing the "public" board menbers from the appropriate state 
agency. Bureaucxats would have the advantage of (a) technical 
knowledgre relevant to the task, and (b) a power base fixn which to 
eodert leverage on ot\er board menbers. The power would flow iron the 
agency k«ad and, ultimately, the Governor. (Ochen, 1980) 

— Drawing a najority of the board lu e aiJ e M fron outside the 
regulated ooofiation. A far cxy frcv one. or twD "toJcen" consimers, 
under this profXMal boards would be dcninated by liy menbers. 
(Begin), 1980) 

— Drawing board madsers entirely of persons trcn outside the 
rriu]atad occupation. Board BBbers could be not only oansanerB, but 
others wi^ relevant oqpertise in fields such as education, public 
health, econonics, health adninistraticn, and health services 
reseairh. (Onhen, 1980). 


18 - 

In the last case, the board oould cnplcsy as oonsultants either individuals 
or a pa^el of techniczd advisors drawn from the regulated field. However, 
because no Becber of the board would ocna fkon the field, ard because 
board wmb en would have cxvisiderable relevant esqpertise of their own, 
they would be li)cely to avoid "capture'* or dcndnaticn by the field and its 
association (s) • 

looatlcn of Bwrflff In thff Mm^n itrattve Stmcture A second 

L^jor r Bocpn a idation to iapcwn aoccuntability has been to strengthen the 
osnnactionB bstiasn re^jlatory boaxds and one or nore state agencdes. One 
appvoBudi has been to centralise the administrative support. Including 
record-keeping, the investigative staff, and other ocnmon functions of 
boards in a single state agen^*, either the health dqpartanent or a cpecial 
depar^iait establiited for this function. 

Another approach xeocmended Ij^ Selden (1970) is to have a single 
board that regulates all health occupations, linked to a state agency that 
provides ell administrative, analytical, and investigative support. 
Sitomnittef^ from each field vould develop policies for that field, 
subject to approval by the full board. 

A third approach is to link related health occupatioru througlh joint 
boards. Rather than the single board envisioned by Selden, there would be 
a nanber of boards, but the nuniDer would be considerably fewer than the 
number of regulated oonqpations. Virginia is moving in this direction 
%dth a proposal for a joint board for r^^veral aUied health occupations. 

Structural changes in the direction of greater accountability are 
highly desirable. To be fUlly effective, however, they should ifply to 
all health occupaticns, not ji2st those that a^e the newest. States %dll 
need to examine and probably revise their practice acts for physicians and 
other health professionals, and to review the stnicbjres of regulation for 
those fields. A double standard, one appliceftde to allied health fields 
and one to aedicine, dentistry, and ti;rBing, is an undesirable state of 

Infoamation for the public rb& regulatory process has been 
criticized for being conducted virtually invisibly. Not only has doing 
business in a closed fadiicn been a barrier to public aocounta&ility, it 
has kept the regulat ry process ttm serving an inportant educational 
function. Ohrouglh state regulation, the publl'? oould becone nich better 
infonDBd about the different health ocopations, their credentials and the 
services they offer. Mdic education also oould increase the awareness 
among state citizens of the iniportanne of occupational regulaticn. Such 
awareness would be likaly to elicit greater interest and participation. 

No single nodel for accountability is obviously si^erior to all 
others. Each state should caploy its own mechanions oonsistent %dth the 
objective of oait-effective public protection. 



The Fadeial Role 

Urn federal govemnent has a very iii()Qrtaiit zole Jji regulating allied 
health personnel. Miile the federal govunment does not regulate health 
ocs^^^pations directly, it has indirect influence an state regulatory policy 
Joy supporting evaluation research, ^msoring policy analyses, and 
fostoring Jnformtion dissanination. It has direct responsibility for 
setting standards for eligible providers under Hadicare, however, and a 
ihared reqpcnsibility %dth the states for standard setting under the 
Medicaid program. Nadicare Oonditicns of Iteticipation, %rihich apply to 
all institutional pcoviders of health servicas, are a powerful regulatory 
tool, because providsrs that do not meet the oonditlons say not receive 

aynent trm the pr o gra m eoooept in cmerg^ency ciroonstances. These 
regulations can be used to define the qioalif ioations of allied health 
personnel iiocking in participn ng hospitals, iBirsing homas, and other 
health care institutions. 

Ihe federal influence is also exerted lay the actions of the Federal 
^StdOsi Omnission. Ihe oanmission has conducted and sponsored research on 
the effects of regulation and has struck down certain anticonpetitive 
practices of regulatory boards such as prohibitions on advertising. 

The federal govemnent has taken an isportant leadership role in 
health occupations regulation, ne pc ac t s issued by CHEN in the 1970s were 
influential in drawing attention to probleBB in the mechanissB of state 
regulat Idn. Reconaendations ocndng out of those reports and out of 
studies sponsored by the labor Oeparbsent helped shape the new directions 
in state regulation. 

Ihe Bureau of Health ftofesr*nns has siqpported studies of 
(xxxpational roles that are \isefui in devising entry and practice 
standirds. The bureau has also helped develop and disseminate infoniBtion 
on state regulatory activities thrtuc|h its siqpport of the Ciearinglhouse cn 
Licensure, Bifonxsenent, and Regulation (CI£AR) of the Council of State 

Ite bureau has also supported the Kt ional OGmdssion for Health 
Certifying Agencies (NCHLA) , a bod/ that Mts standards for orve*^iizatiais 
that certify allied health personnel. Ihe NC3ICA serves a rde analogus to 
COPh in education aooxediting, setting standards designed to ensure that 
certifying agencicB are accountable to individuals sedcing certification, 
to their enployezB, to health care pavers, and to the public, h copy of 
their standards is attached as an appendix to this report. 

The federal Hadicare piujiam has significant iapact on alliad health 
pereomel ttutaug^h the ney it defines ooverad sendees. Ey means of 
regulation, the Secretary of EMS can define the qualifications (for 
exanple, liomsure) of personnel pcpviding services such as physical 
therapy, oooupational ttmap^f spench therapy. 


- 20 - 

Private oGntxol wadbaniaBB 

Rrivate rdoogniticn of acmpe^enx alao offers seme assuranoe to the 
public; it wy takB aevttal fonnB. 

MemberBhip in an aaaociation is an indication that an individual has 
net certain standards for admissicn. Hie standards nay include 
qualifications of edkicaticn or «qperienoe, aooral character, or others. In 
a mnber of allied health fields, a basic xeqairement of aenberidiip is 
graduation traa an education progra m approved by thp Oamnittee on Allied 
Health Education of the MA« Dental hygiene progra .4 are aocxBdited by 
the Anerioan Dental Association. Riysical ttierapy education progiamB are 
accredited by the Anerican Ibysical Iherapy Association (APIA) • 

Oertif ication by a private agency or association generally ispose^i 
anre rigorous standards than those required for association nenb^nBhip. 
Oertification has beat defined as: 

• • «the process by idhich a nongovemnental agency or 
association grants recognition to an individual yJtyo has 
net certain predetermined gu2dif ications specified by 
that agen^ or association* Such qualifications may 
include graduation frcn an accredited or approved 
training program, acoept2ihle performance on a 
qu2Qifyirg exBBiination, anVor ccnpleticn of seme 
qpecif ed unount or type of vork ea^ierienoe (Shiioberg, 

m a paper prepared for this ocnndttee. Carpenter notes that 
oertif icatiGr establishes **standards of i^q!fatc:x»" and then grants an 
individual a certificate allowing than to use an occupational title, for 
exaniae, **registered dietician.** (**Registered** is a very confusing 
term, since it aiy be used to mean licensed, as with registered nurses, 
or certified, as in this case.) Ihis mechanism is, of oouree, analogous 
to oertification by « state, except that it does not include legal 
prohibition against use of the title by persons not meeting the 

Historically liansure %ias ooncemed with mii^iioum oonpeten^, vhile 
oertification %ias reserved to thxe meeting CGnsiderably ^ ^her 
standards. Jn aadicine, for exanple, oertificaticn Ly a . specialty board 
nas (and is) viewed as a *%adge of exDellence'* ^Shiaiaerg, 1984) . This 
distinction is less clear cut today, ^ihm in some fields certification 
attests to basic entry standards and in others it attests to special 

forms al private eocanaditaticn are used as quali^ assuranoe 
wchanisDB fbr allied health personnel. In the context of cxedentialing 
allied health perBcmel, aocredica^don is most ccnnonly refers to a 
process throug' lAiich a private association or agency *^grants public 



Mcognitlcan to a school, Institute, coUege, mivttrsity, or qpeclalizad 
pruyiam of studt/ having net oercain establigtfwd qualifications or 
standards** (Shinbezg, 1984) • Educational aocrsditation is a fom 
of peer xevlet/ that is aeant **to pradjde a professional judgment of the 
quality of the edhxational institution or program** (Allied Health 
Bdbcation Dixectxiry, 1987). 

ISie seound fom of aoczeditation that is a quali^ raontrol 
sachanian fbr allied health personnel is the aoczeditation of ho^itals 
and nursing hcnas hy the Joint Ooanission on the Aocxeditation of Health 
Organizations ( JCPtH) . The Joint OcMimission pcosalgates standards that 
indvde qualifications of key hospital perromel. Memy of ti^ise refer 
to allied health personnel (eee Mhle 7.3) . 

Oonclusions and ReoGnmandations 

In lig^ of potential future shortages of allied health personnel 
and the need to find a reasonedble balanoe between health care costs and 
quality, the ocunittee believes that It is isfsortant to maintain 
flexible utilization of existing personnel Td a variety of rouu^ of 
entry for nev personnel. 

It appears that the proliferation of licensure carries with it 
hi^lher costs to consianers, xedboed access to health sendees, and 
reduced flexibility for sanag^ers. People in health careers are 
inhibited fmn changing fields and from advancing vittdn their fields by 
rigid requirements i npo s od by state regulatory ^lechaninns. Although 
these ccntrol nechanisns are designed and carried out in the stated 
Interest of protecting the health and velf^ of the puUic, their 
effectiveness in this regard has been mixed at best. 

Statutory certification, lAiich legally reserve the use of a titli^ 
to persons with specific qualifications, affords most of the benefits of 
licensure and avoids aany of the costs. In conjunction %dth public 
education, it gives cxxwsDers the opportunity to choose among providers 
knoidedgably. It does not prsvmt oonsmers trm choosing lower-quality 
or lowermost alternatives, it permits institutional eoployers some 
flexibility in their staffing. It permits iii»vation— 1»# careers mar/ 
provide nsv cost-effective methods of diagnosis and treatment. 

nf^ nrroittee reoeamwnrtfl statutorv oerttf toation for fields in 
ifaiA the state de^ mJUiVS^ < ^>Bre is a need fat recMlation^ frfnm^lfff this 
fotia of rsiiiMlation offers most of the benefits cif llQenBu ne but fewer of 
Itf ffPftH* Medlcere and other third^parv pavers Aculd aoomt state 
title caartificattcan as a tarerecMisj^^ ffr mlTliUlTWinmr ftliaibilitv, 
ftiA oertificatlon ren and should >^ g1 immlmtlrpg other 

eliflibilitv criteria the states establish. 


- 22 - 

TAtU 7.3: 4o\f\t ConlMfon on Accrodftatfon of Noiltficort Orgonfutfom' (JCAHO) Accrodltatlon ttondardi for NotpitaU 

f Itld tUMory of Mlovwiv Stondirdt, If Any 

Clinical LiboiMtory 

Madlcal ftocordi 

Physical Tharapy 
Occupational Tharapy 

Tlia diractor ta a aMter of tha Mdical ataff and prafarably a board cartf f iad 
patholoofat. Thara ara auff icfant qualff fad laboratory tachnologiata and auiiportive staff 
to parfona tha raqulrad taata. A qualfffad tachnologiat fa a graduata of an approvtd 
aadical tadmolegy profrM or haa aquf^alanl adicatfan« trafninBi and/or axpariancc; a^eta 
currant la9al rtqufrawnU of Ifeanaura/ragiatratfon; fa currant ly eo^petant. 

A qualfffad dfatfcfan dfapanaaa tfia nutrftfonal oaprjcta of patfant care and aasuraa that 
quality nutrftfonal cara fa provfdsd to patfanta. 

A tioapftal Buat aaploy or havt aa a eonaultant a raofttarad racord acbiiniatrator or an 
accradftad racord tachnicfan. If conaultanta only, asdical racorda auparviaora ara to 
danonatrata coi^tanca. 

8aa rahabilftatfon aarvfcaa 

Saa rahabilftatfon aorvicaa 

Ofractor of radiology aervfca fa to detanaina tba qualff icationa and co^patance of 
dapartaant paraonnal; at laaat ona qualifiad radfologic; tachnologiat ia available; a 
tachnologiat doaa not fndapandantly parfona diognoatfc f luoroacopy axcapt inder cartatn 

Diractor of nuelaar a^dicfna aarvica fa to datararina nha qualif fcatioha and coapatance of 
d^sartawn par ao nnal Mho ara not fndapanda n t practitf onara. 

"Wmii radiation oncology procadiraa ara parfonaad fn tha hoapital, daaignatad qualifiad 
tachnologiata ara aaafywd aa naadad.** 


Respiratory tharapy 

Each fndfvfdual pravfdfng phyafcal rahabf Iftatfan aaryfcaa auat wm,t ralavwtt licensure, 
cartff fcatfbn. or ragfatratfon raqufraavnta. Indfvfdual aarvfcaa ara diffnad, fncludir^ 
oco^tfenal tharapy, phyafcal thara^r* proa\ch«tfc and orthotfc aarvfcaa, paychological 
aarvfcaa, raeraatfan tharapy, aocfal woric aarvfcaa xaach-tanguaga pathology or audioCogy 
aarvf^M, wacatfonal rahabilitatfan aarvfctai. No ^icfffc ataff fng atandards ara givtn 
bayond tha ganaral ana. Separata atandarda raqjf ra that coBiprahanafva rahabi I itat ion 
aarvfcaa ba provfdad *fn an intardiacfplfnary aannar,* ard that tha qualify «id 
apprcprlatanaaa of thaaa aarvieaa annitorad and tvaluatad. 

ftaapiratory caro »irvfcaa ara to ba provided by a auff fcf ant nu*ar of qwlfffad parsornel 
iffidar coapatant a^dfcal dfractfon. If uarrantod, aarvfcaa aro aiparvfaad fay a tachnical 
dfrartor ragfattrod or cartfffad by tha Natfinal goard for Raapf ratory Tharap/, Inc. 
Othar ^Iff fad paramal Btty provfda aar¥<caa coMmurata uf th thafr trafnfr«« 
aicparfanca, and caapatanca; thaaa fneluda MTa or eartff fad tachnfcfana, poraona Mith 
aquf^atant odicatfan or aaparfanca; CfMlff fad cordfOMUHnary tadmologiata, and 
approprfotaly trofnad ifoanaad nuraaa. 

MMiX: Joint Coaniasion an Accradftatfon of Naalthcaro Organiaatfona. 1M7. Accraditatfon Manual for Noapitala. 


- 23 - 

^Die oomnittae endot B e s the establiidinent of "Amrifie** criteria to 
guide states' decisicsns about viiether to ZBgulate health occupations and, 
if 9U, how. Ihese dacisicns tfwuld follav these basic principles: 

1. Ihe protecticn of the public is the sole leascn for states to 
regulate health ooaQn^iflns; 

2. The least restrictive regulatony nadianisB oonsistoit with public 
pcDtection ihould be selected, taking into aocount other means that are in 

3. If, after due deliberation, the decision is made to regulate an 
ooo^tion, it must be followed by a continuing ocnnitment of resources on 
the part of the legislature, the governor, and the relevant «ininistrative 

State legulatoxy structures and prooedkires need isapewhq if they are 
to be effective, m most states the ooqposition of beards, the 
reguircnents for entry, and the flov of infooatim to the public are not 
fully consistent with the public interest. 

gaminrft rffgnnnmdS tlmt states gtrenothen th e aooountabllil^ 
and broaden thft wihUc hww> af thPir raaulatorY statutes an d nrooedure s. 
m the near term, the oannittfle augnests thats 

— Licensing bgnrfS ghWld draw at ItHMft Iwlf gf thftir BIBltnTTTihlr 
frrtn rii»g^^ ^ licensed c nypntlmr Bfntoers should be drawn fron « 
variety of areas of expertise suA as health «dminiBtwi<^<«^, 
floonaninB. nnnaimftr >tffjt4r« >Ain»»^nn, fl,-^ llMlth BfT Vioes research. 

— Flexibility diculd be Maintained to the greatest caetent uoeslhle 
without undue risk of ham to the piblic. Tt^ig my ipe an. for 
instance, allcwing wiltlnle paths to lioens'jre er ow»riiyTpjTy| 

of practice for eone -llfffaTHd pocaipaticns. 

Ihe regulatory p .txjeas dKuld be oonrlirted as openly as possible and 
should produce a flow of infomnaticn to the public, ii eluding: 

o Ihe socpe of practice of 'Uie occupation as defined by state law 
'And regulation; 

o Ihe eligibili'ty zegoirenents for entxy to the occqpation; 

o Basic Infonaation about licensees, including the status of their 
lioense, any disciplinary actions taken by the state, as well as 
basic data sucti as adjcational bacdoground, oollected as part of 
the liowising process; and 

o Board i—iijeiali ip and prooadkiras, especially prooeduras for filing 
oonplaints agednst liomed profissianals. 

Ragulotory boards tfiould be well-oomscted to the state bureaucracy. 


- 24 - 

If tte state rajolras graduation tzm an aocxodited education progxam 
for lioaraure, tha stata ahould take ai!) active interest in the 
aocxeditation ZBgiiimnts to ensure that they are cxnsistent with the 
state's interests. 

FiraUy, tiM oonittaa believes that dKisions lay states, acxxediting 
bodies, ard by taaalth care payees regudlng soope of practice, referral, 
and sjpervision ahculd be better infomd. ftm P"-*"" of Health 
Pmfaasiaie rear othar ttihv ftaoal point- top alliad health PBTBonnelin 
mHS\ ahould ■Donaor a b n »^ wi«» wmkmaen drawn frcn allied henlth. fTthftr 
h«>ith prnfaeaietiB. and flrrm the health and social icimw rwfgarg ^ 

9iiM body, in eenaiitatlfln with other experts and intereatfid- 
partiea. Ag y^A onn«<A»r im^iaa of iH«v. Qost. ouaHtv and aoORSW. Tt 

fiYn"»M* ■"<«^if1? wilfflr? 

Itell-designBd eMpsrinents and denonstrations of innovative roles foe- 
allied health personnsl will provide valuable evidenc* to guide regulatory 


American Dental Associatioi. 1987. Testir^ony before the ICM Ormnittee 
to Stud/ the Role on Allied Health PBTBonnel. Hearing ax Regulation. 
July 1. Ittitional Acaden/ of Sciencm. ftoshingtcn, D.C. 

Anerioan Dental Hygienists' Asbociation. 1987a. Testinony for the ICM 
OoBinittee to Sbxi/ the Role of Allied Health arscnnel Hearing en 
Regulation. July. National Aoadony of SciMcee. ftashington, D.C. 

American Dental Hygienists' Association. 1987b. A paper sutaodtted to the 
ICM Ocanittee to Study the Role of Allied Health Ftofessionals. 
Hearing on Rec^lation. JUly. National Aondany of Scienoes. Mhshington, 

American Riblic Health Association. 1985. 8e)c and Status: Hierarchies in 
the Health Nockforce. March. 

Begun, J. W. 1981. ^fesaionalisn and the Riblic Interest: Rrioe and 
Quality in Optcnetry. Omfaridge, Mass. : KIT Kness. 

Palifamifl Pental Association v. Office of Statewide Health Planning and 
DBvelopnent efc al . 1987. Rxxseedings. August 28. Cal. Superior Oourt, 
Oounty of Sa crame n to . 

Oupenter, E. S. 1987. State Regulation of Allied Health Personnel Trends 
and tterging Issues. Background peqper ocmnissioned by the Institute of 
Medicine Oonndttee to Study the Itole of Allied Health Personnel. 
National Aoaden/ of Scienoes, Nashington, D.C. Utfublished. August. 

Qurpenter, E. S., E. MoCIemhan, and S. Nendt-Hilddsrant. 1975. A Survey 
of National Registries and Certification Boards for Allied Health 
Professions. Hichigan Qooperative Health mformtion Systan. Michigan 
DepertxDsnt of FUblic Health. April. 

Oohen, H. S. 1980. On Professional Power and Conflict of Interest: State 
Licensing Boards on ttial . De{)art3Dent of Health Administration, Duke 
university. Journal of Health PDlitics, Policy and law. Vol. 5, 
No. 2(Suniaer):291-308. 

Cblorado Dental Hygiene ABendkaent. 1986. J te agndagnts to Dental Practice 
Act. Siasnaxy prepared by legal counsel to the American Dental 

CDlorado Department of Regulatory Agencies. 1985. Sunset Raviev State 
Board of Dental fiaonineri. JUly. 


Council of Stata Gov«mnents. 1987. State Sunrise Kogr ams ; Deciding 
Mien to Regulate Health I^ofessicns. Issues in Statue Regulaticn. 
lexingtcn, Kentuclty. 

Council of State Govemnents. 1987. State Regulaticn of the Health 
Ocxxqpatlons and Hofessicns: 1985-86. Final report. March 10. 
leadngtcn, Kgntudcy. 

Council of State Goverments. 1978. Occupational lAcsensing; Questions 
a legislator Should Aslc. March. Lexington, KentucS^. 

Departnent of Health, Bducation, and Welfare. 1977. Credentialing 

Health Marpawer. Malic Health Service. JUly. Washington, D.C. ; U.S. 
Goverment Printing Office. 

Department of Health, Blucation, and Welfare. 1971. Repart on 

licensure and Related Health Persomel Qcedsitialing. Office of 
Assistant Secxetary for Health and Scientific Affairs. June. 
Washington, D.C. ; U.S. Govemnent Printing Office. 

Gauner, G. L. 1984. Regulating Health nnofessicnals; A Reviw of the 
Bqpirical Literature. Milbahk Manorial Fund Quarterly/Health and 
Society. Vol. 62, No. 3;380-}16. 

Goldman, F.. K., W. D. Helms, and S. Williams. 1984. Ihe Regulation of 
Healch Professions: A Guide for State PolicynakBrB. Bureau of Health 
Rofessions. Health Resouroes and Service Administration. Jane. 

Gol/^n, S. K., and W. D. Helms. 1983. Ohe Regulation of the neal^ 
Rofessions. A policy review prepared for the OGooissicn of Health 
Regulatory Boards. Octobc. 

Health Care Financing Administration. 1986. U.S. Department of Health 
and Hman Services. Rules and Regulations. Federal Uegister. Vbl. 51, 
Ho. 116 (JUne 17); 22010-22051. 

Holen, A. S. 1977. Ihe Boononios of Dental Lioensing. Arlington, Va. 
Center for Naval Anal'^sis. 

Institute of Nadicine. 1987. Nechanisns for Oontrolling the Quality of 
Allied Health Personnel. CGnmittee to Study tiie Role of Allied Health 
Bareomel. Rtblic hearing held on JUly l at the National Acadeny of 
Sciences. Washington, D.C. 

Maurizi, A. 1974. Ocxxqiational Lioensing and the public Interest. Journal 
of PolitJcal BooRCsy (82):399;413. 

Mocready, L. A. 1982. Bnerging health care oocqpations; the aystcn 
under siege. HCM Review (Fall) ;71-76. 


Morrison. R. D. 1987. Prtblens antJ Opportunities in Health Professional 
Regulation. Background paper csonraissioned by the Institute of Medicine 
Oonmittee to Study the Role of Allied Health Personnel. National 
AcMleny of Scienoes, Washington, D.C. Ufublished. JVily 1. 

National Advisory Ocnrdssion on Health NarpoMer. 1967. A report the 
coraoittee on health narpower. Vdune 1. Novonber. Washington, D.C. i 
U.S. Govemnent Brinting Office. 

National Clearinghouse on Lioensare, Dtfoaxanent and Regulation. 1987. 
Board MoAaer Training Manual. Lexington, Kentud^: Ocuncil of State 

Office of Statewide Health Planning and Developneint. 1987. Health 

Itoipower Pilot Projects Program: Annual Report to the Legislature and 
the Healing Arts Lioeraing Boards. Novoiter. p.3. State of California. 

Shiiijeig, B. 1984. The Relationship Among Accreditation, Oertifi- 
cation and U.oer»ire. Federal Bulletin (April) : 99-115. 

ShiBfcerg, B. 1982. Ocapational Licensing: A Public Per^aective. 
Prinoecon, N.J. : Educational Testing Service. 

Yngshall. Nies et al. V. State of Oolorado et al. . 1986a. Transcript 

of cooplaint. Col. Dist. Court, City of Denver. Case NO. 86 CV 11964. 
July 3. 

yhriall. Nies gt al. v. state of Ool orado et al.. 1986b. Hearing 
dismissing the oonplaint. Ool. Dist. Court, City of Denver. 




mtroc J.on 

Earlier chapters of this wport have discussed *ifth^J?»,**«^^ 
alli^SSilS^ will be s^^icient to «aetf^ <^ ^ 

xT wCTnJnoTT. naeded to fill iobs to the qualitative inprovanents 
SS^ir^^SS^jlf ^ Sied^th labSlarce is to be responsive 
JS^^iT^^^fTSticular sequent of our society^-thoee requirirg 
^i^SJrSr? .^iSo^tSte^ate not only to .Aiether caregivers 
JSSrS^r^'t^STSSSto offer, but also .Aether servioes are 
J^nS^'SfdSS^in a way that enhances the c^ity of life of 
long-term csce ccrsunieirs. 

aearly. financing policies ore a toy to ^ity, although toe 
availSlf e^iden^^n^^ i«tfis at least has not shown what toe 

1? SSf tSLl^oontrlbute to policy disaassions of^^'S^that 
SfSnTby addresJii^ human resource managanent and «*^tion i^^^^ 

rrur«e of its inouiry. As a nseans of gaining insignt 

r^eaivers was one recurrent issue. The extent to viuch allied heaim 
SorSSSfpSSa^students for loi^-tenn care settings was another. 

Long-Tern care and Its Oonsumers 

Although lor^-term care is defined in a runtoer of different ways, for 
the r^S^of this study it is a hrtad rar^ of clinical, social, and 
^sSSTSpStivrssrviies for people who need assistance « , . 

Sre is the maintenance or restoration of the highest possible 



- 2 - 

level of physical, mental, and socied flmctioning of indlvidueLls within 
the constzaints of their illnesses, disabilities, and ervironDental 
settings (Neltzer et al., 1981; Xhne arJl KanD, 1982) « 

In enphasizing the multiple ^pes of servioes neoessary to achieve 
the hi^^hest att2d^'iable quality of life and peracnal autoxxny, this 
definition has tMD isqportant ixoplicaticfis for those ^iho provide caze and 
hour they interrelate with one another. First, caregivers of mary 
different professions and disciplines, as veil as f <«ily and friends, mist 
be involved. Seoond, this is a process that relies en a flov of 
information oonoeming an individual's needs, services, and potential for 

Long-term care can be provided in institutional settings, such as 
nursing hones (mostly skilled nursing and intermediate care facilities) , 
institutions for the mentally retarded, residential care facilities (e.g. , 
board and care homes) , long-stay hospitals (e.g. , psychiatric hospitals) , 
q)ecialized schools, and hospices, it is provided in anixilatory care 
settings, ir^ the oonnunity througp; day care pr o g rams , and in the home 
through hcrae care services. Some rehabilitation facilities provide 
long-term inpatient care, but also offer specialized ax±ulatory care over 
an extended period of time. 

Althouc|h such of this cheqpter is about the elderly, there also are 
others Who naed long^-term care servioes. Ihey include infants with birth 
defects, develqpmentally disabled children, adolescents vho have suffered 
head trauma or coined cord injury, laborers with esphysema, and elderly 
people with multiple sensory deficits. Ihey also inclvde the chronically 
mentally ill and the severely retarded. Ihe epidemic of aoguired isnune 
deficiency syndrome has fooised attention on the long-term care needs of 
persons with chronic, infectious di seases. 

Because destcgrafhic projections suggest that the largest incz»ase in 
the need for long-term care will ocne fton the aging of the population, 
the service needs of the elderly have received the most attention of 
late. Indeed, the CGmnittee's examination of this topic ooincides with 
the release of two m^jor reports. Ihe first, mandated by Congress, %ias 
oo-chaired by the directors of the National Institute on Aging ard the 
Bureau of Health l^fessions in the Health Resources and Servioes 
Adruimstration. Their r ep ort examines *^the adequacy and availabili^ of 
personnel prepared to meet cur r en t and p r oj ec t ed needs of the elderly 
Americans through the year 2020^. (National Institute on Aging, 1987) 

A seoond study was conducted by the National Teisk Faroe on 
Gerontology and Geriatric Care Education in Allied Health. Established by 
the American Society of Allied Health Professions, the task force explored 
the inplications of demognqphic and dissLxse pattern trends for allied 
health professional education and practice (National Task Force, 1987) • 

The two studies reinforce some of the thesnes we will develcp in this 
chapter. An aging population in need of Ictig-tem care will incareasingiy 
doniiiiite the practice of nest health care workers and will create pressure 
for greater nunijers of personnel In total. Preparation for t-his future 
will require significant Interventicrs in the way we educate and socialize 
students to treat patients and work with other health coUeagues in the 
long-term care env^ircment. 

Detenninants of Need for Janq-Term Care 

A nunijer of factors— health and functional status, inocrae, living 
arramejnents, marital status— influence v*» is liJtely to beoane a 
long- tern care oonsuner and the types of services they receive. A review 
of tl-^e factors reveals why there is oonoem about the capacity of the 
health care system to meet its future challen^: 

o The need for the fonnal eappcact of nursing heme care increases 
sharply with age as do the effects of chronic disabling disease. •C-i 
utilization rate for persons 65 to 74 years of age is 2 percent; 6 peroenv. 
for those 75 to 84; 23 percent for those 85 and over (Rice, 1985) . 

o If current Bcrbidity, disability, and functional dependence lates 
and patterns oontijiue, by the year 2000 abcut 50 percent more 
noninstitutional elderly will require the help of others in daily living 
activities than required such help in 1980. At the same time, the nunisers 
needing nursing hones could increase by 77 percent. In addition to the 
elderly, it is estimated that the ninber of individuals under 65 years of 
age who are functionally dependent due to chronic disabling disease may 
well eqoal those over 65 (ICM, 1986b) . 

o M&rital status influaioes the use of long-term care services 
(especially nursir^ hones) because people withcwt spouses may not have 
anyone to provide the personal care that would allw than to stay in the 
csnminity. In 1985, 84 percent of the elderly in rursing hemes were 
without spouses, oonpared with 56 percent of functionally iipaired people 
living in the oonraunity (NCHS, 19e7a; Macken, 1986). If wcmen continue 
their more rapid mortality Inprovenents than men (ICM, 198a>) , there will 
be mare umarried qpouses requiring rursing heme care. 

o Infectious disease patients are liJcely to cause a noticeable 
increase in the demand for long-term care and the services provided ky 
allied health personnel. Ihe nuniser of AIDS patients junped frcm 183 
cases in 1981 to more than 49,000 cases at the end of 1987 (C3enter for 
Disease Control, 1987a) . Ihe U.S. Public Health Service estimates that 
1 5 million people are alieacJy infected with the AIDS virus (Center for 
Disease Control, 1987b) . Althou^ relatively saall prcportions of AIDS 
patients nay need irstitutional long-term care (those with danentia, for 
Scanple) , there are indications that oonitunity care could bring a large 
denJd for home health servicaes (Widdus, 1987; Braun, 1987: Icng Term Care 
Kanagement, 1988). 


o More than a guartei^inlllion infants are bom in the U.S. each year 
with physical or mental defec±s (March of Dimes, 1987) . Despite advances 
in prenatal detection of disoases causing disability, data from the 
Centers for Disease CJontrol show that the incidence of most types of birth 
defects remain substantially unchanged during the period 1970-71 to 
1981-83 (BdhDcnds and James, 1984) . 

o For the past 15 years, the level in the U.S. population of the 
severely develcpnentally disabled has remained steady at approdiiately 1.6 
percent. However, the type of care that they receive has (ttmged 
dramatically during that time. In 1967, many lived in large public or 
private institution. Today, ttere is an increasing demand for relatively 
small connuni^Hbased facilities. Ihe mnober of such facilities has grcwn 
frtan about 4,400 in 1977 to 20,000 in 1986. With these structural 
changes, some researchers hove detected a substantial imease in staffing 
intensi^ that is lUcely to centime (Braddock, 1988) . 

Ideally^ an assesanent of changing demogre^iiic and epidemiological 
patteiTs, such as those described above, should lead to an understanding 
of the preventive, curative and rdiabilitative needs of persons vho beocme 
elderly or ill. Uhderstanding the care requirements clarifies the type of 
education and tzBining programs caregivers ouc^t to have to meet the needs 
of patients— all of uhich should lead to the developient of appropriate 
education p rograms. 

Uhfortunately, this idealized sequence does not happen for many 
reasons. Oiief among these reasons is lack of adequate financing limiting 
who gets into the formal care system, the amcxmt and quality of services 
provided, and the attractiveness of long-term care to health %«orkers. Ihe 
scope of the study does not permit exploration of the broader financing 
problems of long-term care; tiie ccnrdttee devoted its attention to 
possible education strategies and human resources managenmt interventions 
in nursing homes, home care, and rdiabilitation facilities— "three settings 
in vAiich allied health personnel play vital but diffr'»it roles. We will 
also e)q)lore the problems in these settings of integrating allied health 
services #^ith those of other caregivers, including aides, yiho may 
initiate, collaborate with, or at times substitute for services of allied 
health personnel. 

Nursing Homes 

The majority of institutional long-term care is provided in nursing 
homes. In 1985, there vrone 19,100 xursing homes with 1,624,200 beds. 
Ihis represents a 22 percent increase in the niDDber of homes and a 38 
percent increase in the nmfcer of beds since 1974. (NCHSb, 1987) 

Despite the demogrzqphic and dififtase pattern changes described 
earlier, the nation's stodc of nursing home beds is not keeping pace with 
the growth in demand, let alone probable need. The result is that nursing 
hones usually have hiG|h occupancy rates and long waiting lists allc^dng 
operators to select **li^ care** and private pay patients. Ihis works to 

- 5 - 

the dfltrimant of those \iho axe poor ard most in need of care. Efforts to 
turn this around are oonstrained by states seddng to limit Medicaid 
budgets through oertif icate-of-need regulations that control the building 
of imi beds (AHCA, 1985; AHCA, 1986) . Future growth will depend on the 
federal governnent agreeing to enlarge the flov of dollars into long-tern 
care or hewing create inouitives for the nail but grwing private 
insuranoe aarket. 

In 1985, there ware about 1.2 mlUicn full-tim&^eqoivalent nursing 
hone cnployees. More than 700,000 prwided personal care, of lAiich 
mrse's aides and crderlies vers the largest group (71 percent) . ihe 
nunber of allied health professionals providing nursing hone care on a 
salaried basis is OGqparatively onall. In 1985, there vere appraximately 
7,000 dieticiaiVhutritionist, 2,900 registered pl^sical therapist, 2,600 
registered medical record adhninistrator, and 1,500 registered occupational 
thenqpist FZEs (NCHSb, 1987, Strahan, 1987) . Daspite efforts to constrain 
bed growth, BIS projects that nursing home wployment will grow to the 
year 2000 at an annual 3.8 percent rate, or about 3 times the p rojected 
growth for the overall econcny (ParsoniJc, 1987) . 

Nursing Home Residents and the Organization of Que 

Ihe typical nursing hone resident is an 80-yaar-old white widow who 
has several chronic medical conditions. She was admitted to the nursing 
home about one and a half years earlier after being a patient in a 
hospital or other health care facility. Seventy-five percent of elderly 
residents in 1985 were female; only 6 percent were blade and less than one 
percent were other races. Ihe fact that a hi^jher proportion of the 
elderly lAiite population (5 pertsent) receives nursing horns care oonpared 
with blade (4 percent) and other races (2 percent) is liJcely due to 
substitution of informal care of non-^nihites in the home for 
institutionalized care (NCHS, 1987a; Madoen, 1986) . 

A patient enters the nursing home fay physician referral or by direct 
application of the family. All services must be prescribed by a physician 
and fUmidied according to a written plan initiated by the physician. Ttya 
care plan is developed in consultation %dth the appropriate nursing and 
allied health personnel. Par exanple, an oooqpational ttierapist assists 
the physician by evaluating the patient's level of functioning, by helping 
to develop the plan, by preparing clinical and piogi 'e ss notes, by 
educating and consulting with the family and other agency personnel, and 
by participating in in-service prograaos. Occupational therapy assistants, 
tinder the siqpervision of a qualified oooqpational therapist, perform 
services planned and (falegated by the thttqpist. Ihey assist in preparing 
clinical notes and progress reports and help educate the patient and 
ftaaily (Occupational Therapy Hedicare Handbook, 1987) . 

- 6 - 

lb be csertif ied under JteJicare conditions of participation, imirsing 
hones oust assure the availability of allied health services. But the 
lUBber of fUll-tine allied health persomel oqplcyed is snail because ocst 
nursing homes find that xeii±urBenent does not stretch to pro'/Ide nary of 
these services. To conserve resources, consulting arruigeDents and 
part-tixne %rork are the nonn fbr therapists and other allied health 
yfarkers. Mhen funds are available to hire allied heedth personnel, nary 
facilities ippear to have difficulty in attracting such staff. 

Registered nurees sipervise or ccxirdinate the direct care of 
patients, and one tool for enhancing oonounlcatlcn among caregivers is the 
team meeting. Ihe regularity of these meetings viuries among nursing 
hones. Often headed by nurses, the team nay not neoesseurily include 
allied health personnel. Optimally, the meetings should not only provide 
an opportunity to exchange infomatiGn about patients, but also serve as e 
way of organizing care that best responds to individual patient needs. 

One approach to incorporating edlied health personnel into a team 
eff€»± was described to the ICM's Oomnittee on Nursing Heme Regulation. 
In this nodel allied health qpeciedists serve a stron:; educational rather 
than direct patient care rde: 

Each nursing unit has a primary care team onqpoocd 
of the physician, head nurse and social worher for 
that unit. Ihe primary care team guides th^ XBsident 
care plaaiing. All mearibers of the team have an equal 
voice in this planning. Auxilieuy staff such as 
pl^ical therapists, occupational therapists, leisure 
activity specialists, dietetic techniciars, etc. , are 
assigned to each unit and work with the primary care 
team. In addition to individual relatlorships, unit 
team menbers plan and assess resident care in a 
variety of organized meetings. These types of 
meetings may have a different focus. For exanple, 
ii2nit clinical meetings focus on residents' psycho- 
logical problens, rehabilitation rounls focus on 
physical therapy. These meetings have cne thing in 
ocnmon, however; they include all care givers 
including nurse aide staff. (Boehner, 1984) 

As a practical matter in today's nursing home enviroraent the 
rdiabilitation services that allied health personnel mi^t be directly 
providing are either absent or stretched across a large patient base. 
Linkage of allied health expertise to the activities of nurses and aides 
becomes a critical element in how well patients can ijii)rove their 
functioning. Ihe linkage is dependent on both opportunities for effective 
conimnication between allied health personnel and the nursing staff as 
well as the ability of other caregivers— aides in particular^— to receive 
and act tpon the advice of the all.ed health practitioner. 



- 7 - 


Bie quality of life for patients is significantly affected by the 
giiality of care prcvided by the caregivers vho have the most frequent 
patient oontacts. Ihese are the aides. Ihe typical nurse'j aide is a 
WGoan uho is about 35 years old, and vto has no more than 12 years of 
education. She has little or no training in nursing skills. She has been 
eaqployed in her current job less than two years and has less than five 
year's total experience as a paid caregiver (NCKS, 1987; Strahan, 1987) . 
Most aide; are %ihite, but a sizable portion (32 percent) are blac^ or 
other minorities, higher than their representation in the labor force as a 
%yhole (13 percent) (Kahl, 1987). 

On an average day, the aide has a vide range of activities. For 

TIhe aide is expected to do passive range-^f-motion 
exercises for stroke or paralysis patients. If 
hanorrhaging occurs, she must innediately elevate the 
bod^ and opply pressure before cedling the nurse. She 
oust use correct body mechanics or seek help in moving 
patients. The edde is expected to reconcile food 
service deliveries with patient's dietary 
restrictions. She regularly observes changes in 
patient status such as whether a patient's toe nails 
need to be cut and \ihether decubiti are present. She 
monitors food and water intake, and enctional states. 
A capable aide would notice potential circulatory 
prablenos, changes in t0!iperature, and paralysis. 
Aides also provide drjan, wrihkle-*free bed linens. 
They receive and retum linens to the laiindry or food 
trays to the kitchen. Aides are e)^?ect£d to initiate 
and facilitate interaction with residents and to 
assist in and encourage ambulation" (Brannon and 
Bodnar, 1988). 

As the foregoing list of duties illustrates, aides carry large 
responsibilities for which they may have little training or experience to 
prepeune then. There is also little status, recognition, or ocqpensation 
for this key role. While most often viewed as part of the nursing staff, 
the problems aides encounter are, nonetheless, ones that also concern 
allied health practitioners or overlap the responsibilities of allied 
health assistants. For exanple, both nurse's 2ddes and ooaqpaticnal 
therz^ assistants play a role in patients' daily hygiene and 
refaabiliv3tion exercise progranis. 



- 8 - 

Ihe iBoent Institute of Madicine report on nursing hare tBgulation, 
in XBlating improved functioning of residents to their sense of 
well-being, noted hew aides shape the residents' social world: 

• • • 80 to 90 percent of the care is provided Isy 
nures's aides and the quality of their 
interacticns with the residents— how helpful, how 
ftiendly, how ccnpetent, how cheerful they are 
and tiaa nuch they treat each resident as a person 
worthy of dignity and respects— makes a big 
difference in the quality of a resident's life. 
(ICM, 1986a) 

Because of their ijiportance to the quality of care provided in 
nursing hones, as well as in hone care, the levels and content of aide 
training has been a focus for reform, it is interesting to note that the 
reconraendaticn ftcn the IGM Nursing Home Standards Odmtdttee to make ude 
training a regulatory standard was one of the few exD^>tions to an 
ajpproacti that relied principally on patient outoonie mea^jres in assuring 
quality. Follcwing the ICH's raoonniendation, the Health Care Financing 
Ad&dnistraticn proposed a rule requiring zddes to reoei^*e a minlinum of 80 
hours of training (Federal Register, 1987) . Shortly, tnereafter a 
provision of the Medicare law requiring 75 hours of aide tredning was 
enacted through the Ctanibus Reconciliation Act of 1987. 

In many nursing homes, annual turnover is extremely high for aides, 
and in sane cases all of the aides may be replaced in the course of a 
year. Hi^ turnover has been lixiked to several factors, most iiiportantly 
enployee pay and benefits. Aides generally earn only about $10,000 per 
year (Kahl, 1987) . It is not surprising then that during site visits, the 
ooDnittee heard reports cf aides ctenging jobs for a 25-to-5CK»Tt per 
hour inczease in pay. 

In addition to turnover, earnings also play a part i^^ a growing 
recruitaient problem. We have already referred in this report to the 
general tightness of the labor market for technically orieiitod personnel. 
Similarly young, low wage service workers will also be at a pranium. Sane 
in tl^ nursing hone industry see themselves in direct cciqpetition for 
these euployees with the fast-food industry, for instance, which is 
beginning to offer higher starting salari^ and the attraction of greater 
opportunity to socialize with peer %rorkers in a less onerous atmoqphere 
(Ksrschner, 1987) . Because of this coqpetition, there is increasing 
interest ^n targeting older individuals for recru^ ment. Ihesc older 
WDricers (vhon McDonedds fast-food restaurants also is recruiting) , whose 
cohort will be expanding in the population, already represent a sizable 
portion of the aide-level workforoe: 40 percent of aides ar» over the age 
of 35 (Kahl, 1987). 



Biiy clone, ho^^ever, will not solve rBcrultsent, retention, and 
turnover problems. Aides' poor delf-peroeptions and lack of involvement 
in the decision-making prcxsess regarding their responsibilities will 
require action by Tnanrmjriiyiil. (Vfeoonan and Berkenstodc, 1984) • Lack of 
career ladders, work scheduling, nanagenent atcitudes, and understaffing 
are other oomnon frustcatlons voioed by aides themselves. 

Ill lic(ht of their criticed role in patient well*-being and 
rehabilitation, the (juestions of how vatxti tredning aides need to function 
effectively, how they relate to others \te provide nursing and allied 
health services, and vhat kinds of pay and careers suit their level of 
responsibility are questions that nursing home management cannot avoid. 
If in the future we are to have sufficient nunbers of people to carry out 
the responsibilities that aides pres^fitly assume, the nursing heme 
industry will need to ocme to grips not only with inprcrving low wages and 
working conditions, but the organizational challenge of deploying staff 
wisely. Allied health caregivers in nursing homes will necessarily beccrne 
involved in these issues. E^ihanoed pay and responsibility for eddes will 
require that edlied heedth personnel forge new working relationships and 
increasingly accept pedagogicad roles. 

Hone Owe 

Home health care, often viewed is a substitute for nursing home 
placement or extended hospitalization, shares many of the same generic 
problems of nursing hemes. Agencies have difficulty recruiting and 
retaining staff at the edJe level and teamwork is frequently inadequate 
among nursing and allied health personnel. Ihese problems are exacerbated 
in home care, %duch fay its very nature requires staff to operate with less 
direct siqpervision. 

Heme Headth Agencies and R^rsonnrl 

Althcu^ formal ocraiunity care such as frcm heme health agencies 
accounts for only 15 percent of public long-term care expenditures, it has 
been one oi the fastest growing segments of the health care industry. The 
nunber of Medicare-<3ertified agencies tripled from 2,212 in .972 to 6,007 
in 1986, but dropped slightly to 5,877 in 1987 as agencies reacted to 
restrictions in Medicare rules. In 1986, £here were 105,038 salaried, 
full-time esployees. Registered nurses represented the largest category 
(34 percent) of personnel followed by aides (25 percent) . About 6 percent 
of the eqployees were physical therapists, 2 percent vere occupational 
therapists, and 3 percent were speech therapists (National Association for 
Heme Ctooe) . P .^use seme therapists operate on a contract basis or work 
in agencies not certified by Medicare, these proportions probably 
understate the nunober working in home care. For exanple, about 22 percent 
of physical therapists woric at least part of their week for heme health 
agencies (American Fhysical Iherapy Association, 1987) . 

- 10 - 

Ham;? ^Ja^ath caire ifi not ocrvered by the proqsactive paynent system 
Ixit, 6l^^^ 1985, linit^iticans have been applied to zeijiixirBanent for hcne 
health services. As a result, many ajencies choose rwt to participate in 
Medicare and limit their clientele to private-peiy patients. Ihe National 
Association for Heme Care estimated in August 1987 that there vere an 
additional 3,700 agencies not certified for Madicare (National Association 
for Hcc3 CSare) . little data are available on recipients or reinbursenent 
under private insurmce. Medicaid also can induSe hcne health benefits, 
but payment levels have fluc±uated greatly over the past decsKte arrl v^ 
considerably by state. In 1987, Nev York accounted for 77 percent of all 
Medicaid home health e3qpenditures oonpared with California's 7 percent 
(Rabin and Stoclcton, 1987) . 

HcD£ Health Clients and Organization of Cdoce 

About 80 perc^ of home health rec^)ients are post-hospital 
referrals. Ihe typiceQ process of referral fron physician to nurse to 
allied health personnel can opcrTite smoothly, but also masiks a set of 
unea^ relationships. 

The nurse's view of her role has been characterized by Mundinger. 
**Hhen the referral and physician's plan of care are received by the 
agency, an initial nurse assesanent visit is m^de within three days. When 
the nurse's plan is approved, it beocnes the operational one for patient- 
care and r^lacas the original physician order: 

Ihe plan devised by the nurse includes all of the 
care to be given as well as rtKxnnendatio'^s for 
referrals. Far exanple, if physiothere^ (sic) is 
beixvj considered as care needed, it is the nurse who 
makes the assessment visit to determine whether it is 
in fact really necessary. Ihe nurse r^i t^ on the 
need for a hcrae health aide. Ihe nurse also can make 
referrals f other hone health services such as 
occupational there^, speech therapy, and social 
%^arker services. The plan that is submitted to the 
physician for signature includes all reisfaursable care 
the nurse deans necessary. It also includes illnofis 
prevention and health maintenance care required b^^ the 

Physicians, as do most professionals, tend to 
inplesoent the there^ies that they know best, value, 
and use in their own wor)c. Oherefore, home caie, 
traditionally a low-technology and low^-cost venture, 
under Madicare has become a service filled with 


- 11 - 

hi^i-O06t cazB. It is not unusual for a physician to 
otddr a battery of coqpensive blood tests rather than 
mice a hone visit, or utilize physical therapists for 
routine range of notion or anbulaticn of honebounl 
paticffits. Riysicians should be aware that nxrses can 
teach families to carry out these cxercisoo or that a 
visiting nurse's asaeomtcnt and history can tell more 
than blood tests in Aany cases" (Mmdinger, 1983) . 

The nurse ar r an ges for various services to be delivered separately 
by therapists or aides, none of %hcn nay seet with each other 
faoe-'to-faoe as a team. While important infonnatiGn oan be exchanged 
through the record, the amount of direct coUabcratiGn for patient 
problan solving among carr^ivers is often minimal. 

Because of this p?.^:em of care, groving attenticn has been paid 
to the issue of vho is the care manager, idho controls the mix of 
services, and how aultiple caregivers coordinates their services. Ihe 
care manager (or case manager) is responsible for ensuring the 
coordination and continuity of servioes (Levine and Flendng, 1986) . As 
the quotation above illustrates, nurses presently see themselves 
fulfilling this function. But physicians and allied health personnel 
are not necessarily vdlling to concede this point. 

Ihe following rqsresents the viewpoint of the Health and Riblic 
Iblicy Ooranittee of the American Obllege of Riysicians, Which has 
argued that physicians ougjht to be actively involved in assessing the 
continuing functional as well as medical needs of hond3ound patients, 
and advising patients on the use of hone health services: 

Althougfh Madicare requires the physician to 
certify a Ixxne health trt^tinent plan, typically the 
physician describes the patient's medical condition to 
a home health agency, and a registered nurse actually 
develops and inplaoDents the hone care plan. 

Riysicians should play an isportant rd)^ in hone 
health care, not only as providers of inadioal care, 
but also as case laanagers and coordinators of oare^ 
Riysicians should assure that their patifsits continue 
to receive high-quality medical care after discharge 
frcm a hospital rod lAiile receiving ^xeatment in the 

unfortunately, the current reij±urBanBnt systen 
does noc provide any inoentives for physicians to 
becone mcxre involved in hone health care. Tine qpent 


12 - 

oaaBunlGatlng with hooa haalth oaxB perBcamel, 
def/ising hCD9 txBatsMt plans, ocnpleting 
certification tocm, consulting with the patient and 
iamllv by telqphm, or traveling to a patient's hcma 
is not xeii±urBable. Xnteed, HCFk maintains that 
tt^ese costs are subsuisad in tihvsicians' paystt.its for 
office visits and hone visit, .aaaltii and Public 
Policy OcDsdttee, 1986} • 

Trm tha perspective of allied health fields, the 
interdisciplinary grtxp that ccnstitutes the hone health team, **is 
overly depoident qxn a single type of professicn, the physician, to 
vrite orders.** The neAds of the patients ou;^ to determine whether 
r ^ o f^ management is aoocnplished by an individual therapist, s ocial 
worker, nurse, or a team. But current reisburaenent practices, allied 
health leaders have argued, do not give the team adequate control over 
ts*: resources are allocated for the patient's care plan. (National Teisk 
Furoe, 1987) 

Without a reimbursemBRt mechanism that Jieates incentives for 
coordinated and aqppropriate use of the hrme care services potentially 
availebl:) ftom a wide array of providers, it will be difficult to 
overcome problems of f lagmen t ation, diqplication of services, and 
intsrprofessional coo{)etition. Short of such a payment scheme, the 
solutiora coDraonly cit*d in the home care and case management literature 
offer the best hope for i np ro v anent. These include greater use of team 
conferences, moi'e conplete documentation of patient records, increased 
attention to defining ttm ftmctias of different ^pes of practitioners 
in home care, more vigorous case management on the part of heme health 
agencies, and educational expeiJLenoes that prepa.*:e students for 
interdisciplinary collaboraticn and case manage^^nt (MaciRae, 1984; 
Steixihauer. 1984; T^^^aooan, 1984). 


In moving trm consideration of nuonsing hones and home care to 
rehabilitation fa(;ilities, a major distinction arises: the team 
approach to clinical management is a well-recognized fixture in the 
rehabilitation liorld. 

OolldxsFBtive behavior among health care practitioners is 
reinforced by the fact that rehabilitation patients are generally 
treated for a flmcticnal rather than a medical disability. By 
regulation, fbr Medicare reimbursement patients must receive a mlnlmmi 
of three hours of physical ttiere^, occupational therapy, speech tberap^ 
Brd/ar orthci^ ist and prosthetist services per day for five day per week 




(Mction 3101.11 (D) (3), Fart A. MadicaxB Intennedlazy Manual). Ihe 
pati«nt vhD r i ji' n fi n m or no longer in p ix^ v es in function ntist be 
dischuged into another care envircnoent. Ihe current payment system 
places a premium on fuvtional assessaoDent and progression toward 
ijqproved functioning. 

Otere has been significant growth in rehabilitation p io gia iu s in the 
last thirty years and a 50 peroent growth in the number of 
rdiabilitation beds in the last f ive years. Ttsday, there are 73 
rehabilitation hoepitals vith 6,225 beds in the Uhited States. Ihere 
also are 512 distinct rehabilitation units vith aLrut 13,000 beds in 
general hospitals. Rehabilitation facilities are currently cooeniJt from 
the Medicare pro^)ective payment system, because an equitable predictor 
of reeouroe oanswption on %<iich to base pe^nent has yet to be found. 
(Rehabilitation aervioes in intensive care and in mediral-surgical units 
of acute care hoepitals, however, are not exenpt.) A ip mylin a t ftl y 32 
million people are physically disabled, and 12 million people severely 
disabled. Ihe nunters of severely disabled have increased and will 
continue to incanease with the aging of the population and with 
tedhnologioal advances that inprove proepects for children with birth 
injuries or congenital defects (I^qparxe, 1987; England, 1987). 

Because patients in rehabilitation settings need qpecialized and 
intf^ive services, the staff typically includes full-time dqtartaents 
of physical, oocqpational, and speech therapy, red - logical and 
laborat^ services, and scmetiines respiratory therapy. There are also 
social, psychological and vocational services on a consultant basis. 
Althouglh the staff iii rritiabilitation hoepitals typically Jocafk in teams, 
some e}qpert^ call for an additional category of case managers to help 
assure appropriate and tiniely referrals, reduce admission delays, and 
assess insurance gaps (I^eparxe, 1987; England, 1987). 

By tradition, allied health practitioners, with nurses, play a 
central role in the delivery of care as a team. For exanple, the ratio 
of FIE physical thereqpists to registered nurses is 1:2 in rehabilitation 
hoqpitals oonpared with 1:43 in acute care hoqpitals (American Hoepital 
Association, 1987) . A recent survey by the National Association of 
Itehabilitation Facilities (NARF) showed that 65 percent of the total 
cost in rdiabilitation hospitals was attributable to staff salaries, 
wages, and ftinge benefits. This ocnpares with an average of about 57 
peroent for all hospitals. Intensive use of physical thertqpists, 
ocopational therapists, and specialized nurses results in hi^^her 
personnel costs in rehabilitation hoqpitals. Salary increases of 7 
percent a year for physical therapists, 6 percent for ocoqpational 
therapists, and 5 percent fdr Ksrses sinoe 1985 reflect the difficulties 
these hospitals are eaqperiencing in attracting personnel. Ihe 
oonpetition for these enployees has also resulted in growing recruitment 
costs, and Ixcreased use of ccntract personnel. (MARF, 1987) 

Er|c *302 


A surra/ of 43 xvhabilltaticn facllltiw in QBdlfcnmia found 
vacmcy rates of 15.6 peroent for physical therapists, 8.6 peroen t for 
oocqpational therapists and 10.7 peroent for ipeni-language 
pathologists. Vhcancy rates for pl^ioal therapy and ooopatiaial 
therapy assistants eacoeeded 20 percent. Among the oonoeeiiMnpoe of these 
staffing prablens, 24 peroan;: of the r es pcnden ts eoqperienoed admission 
restrictions, 76 p e r oen t show an iacxict on outpatient waiting lists, and 
58 peroent delayed initiation of rmi services or curtailed existing ones 
(California Association of Rehabilitation Fecilities, 1987) • 

Rehabilitation hospitals see thssselves at a disadvantage in 
oonpeting for allied health persomal in ti^ labor sarkets. They 
attribute their difficulties to students' lack of es^osure to the 
potential of a career in rehabilitation, Wiich is pnoeived to be an 
arduous, unattractive jcb, bringing little reoognition. Rehabilitation 
administratoTB fear a ccntinoing diversion aC personnel to more 
attractive practice settings jJhesce patients are less in^Acitatad and 
earnings are higher. 

A brief examination of the e>qperienoe of the Veterans 
Administration (Vk) , a major prtvider of rehabilitation services in the 
nation, offers some insi^^hts into the prablens often faced by many 
rehabilitation facilities, <especially those that are public 
institutions. While the VA labors under personnel and other constraints 
p eculia r to public facilities in recruiting and oonpensating its 
rtployees, the iaplioations of personnel shortages and coping strategies 
arb an instructive previev of ^t the future for all rehabilitation 
facilities could be under widespread shortages. 

The VA E>qperienoe 

Interviews with central office officials and chiefs of physical 
therapy and ocapational thereqpy at a nmtoer of VA medical centers, 
revealed a consensus on a nunber of points. Ifeufty of the centers' 
recruitment anVor retention prcblens are due to cssnetition for these 
ocopations in the nonfederal sector. Sitetitution of lees qualified 
caregivers was inftegMnt, althoug(h health care delivery eervices were 
sometimes curtailed as a result of the tfioctage. Ihe proUfln appears to 
be worsening; patient load is increasing lAiile physical theriqpy and 
occupational then^ staffs continue to decrease. 

At one medical center in a mid-Atlantic state, half the physical 
therapy slots were vacant. Althouc(h pt^sical thorapy assistants are 
cnployed, they are not used in lieu of licensed physical thenqpists 
because they are not permitted to evaluate patients. The w wl l ffa l center 
Miploys six aorrective therapists (a type of rehabilitation personnel 
used mostly in the \A) , but they too are ccnparatively limited in the 


^pe of care they axr permitted to pio/ide. A corrective therw^ist is 
arsignad to the unit to assist patients in waDdng. Also, because of 
lack of staff, the physical therapy treatiBent rocn in a newly tuilt 
nursing hone care unit remains dosed. The chief of physical ther^ 
%A» carries a full patimt load in an effort to offset the elvartage, 
stated that nonfederal aqployers in the area %«re paying $24,OcX>-$28,000 
for new graduates while the 7A starts than at $18,000. She added that 
the presunption among mny rroent gradiiates is that they ultimately vill 
enter private ponctioe. In ^ler coqperienoe, this differs maricedly faan 
the goals ard assunptions of physical thersqpists in the past, most of 
vhcn apoit their entire carvers aiployed by nadical facilities. 

A large nedical center ir. Southern California has a large geriatric 
patiei^ population, a qpinal oord injury unit, and large orthqpedic 
caseload. Ihe colter oqplcys a rmber of well-kncMn specialists in 
pt^ical therzqpy. As a result, recent graduates flocJc to the nedical 
centar for the quality of the training they can receive there. 
Recruitment success is high; vacancies are relatively low, but physical 
therapists typically raair. no more than two years. Bnis, patients are 
treated for the ncast part by young, inexperienced personnel. 

A relatively anall Southern medical center cited both physical 
thenmist and ocoqpational therapist recxuitseit prcblens limiting the 
nvbec of bedside treatments provided. Ihere are physical therafy and 
occctaticnal then^ education p iugi au fe in this city, but the 
institutions have been unable to recruit graduates before they relocate 
to other geographic areas ^ftiere the pay is higher. Because the 
department is too small to require a chief of service, the medical 
center needs an experienoad occupational thftrapist before it can recztiit 
recent graduates Mho will need seasoning. 

lack of ooapational thenqpists in another Southern medical center 
has resulted in slight mcadifications of the duties of the assistants and 
such adjustments as pt xjy i ' fl u cutbacks and delays in starting rmi 
ptoaaas. The chief of osa^aticnal therapy stated that nonfederal 
ooamational therapy jobs in that city pay $4,000-$5,000 more than vtot 
the VA pays, and it is virtually iiqpossible for the to hire 
eomerienoed therapists. ';i)e situation seens unlikely to isprove as a 
recent survey found that are 54 job openings in oocqpational 
therapy in that city. 

At a fiOBll rural VA medical center in the northeast, physical 
thenpy slots have ranalned vacant for as long as twc years. In 
addition to its lack of salary oonpetitiveness in a region with hi?(h 
demand, this hospital also believes that its large geriatric popilation 
does not offer the variety that many practitioners seeik. 

As dIfiCMssfd in Chnpter VI and in the Vk case exasplos, health care 
administrators lybo face perscnnel shortages have relied en scDe strategies 
to handle the deficdencies in the short run. Tbeae stratagies include 
SKbensive use of overtime, targeting servioes to the patients most liJcely 
to benefit ttm than, and downward substitution (or czoss-substitution) of 
allied hbdlth personnel to the extent that vegulatiGra permit. In the 
long run, unless rehabilitatlcn facilities are willing to reccncile 
themselves to the sorts ol adaptations we have dpisnrihpd in the VA cases 
the/ will have to isprove their capacity to ccnpete for allied health 

The ccmnittae believes that the public will not wish to nor should 
accept service ocnpraaises in the quality and availability of 
rehabilitative care due to major shortages in allied health perscnnel. 
Althou^ current data and analytic techniques are not capable of 
specifying the nunbers of ( trsonnel needed above those who are li)cely to 
be dp uwn d e d under current reijiixirBenait and human resources policies and 
practices, in the ccnnittee's jidgment, rehabilitation facilities will not 
fare well unless the siqpply grows substantially alcng with an increase in 
the share of those dioosing to engage in this difficult work. 

As w have noted throuc^hout this report, salary adjustments are an 
inevitable response to this ooqpetition. Indeed, the VK has soug|ht 
exeoptions fixm Oongress on salary scales. But along with these 
adjustments aaist come a HDre careful and sustained rethinking of the 
services provided and «ho provides them. Die initiatives to do this are 
liJoely to ocdb frcm health care delivery sites atteanpting to cope with 
service demands and constrained budgets, but educators should not dista^i^e 
themselves trm this rethinking process. A new relationdiiip between 
health care and academic institutions must be forged. Our rwcsn^idations 
in the next section address the nature of this partmcship. 

Oonclusion and Reccmnendationn 
In this chaster, the comnittee has concentrated on three generic 
hunan resouroe problems that plague the provision of long-term care: 

1. Minimally trained peraomel are often the primary patient 
caretakers, especially in nursing hemes and heme care. As a result, there 
is too little attention to the linkage between nursing and allied health 
services in the hands-cn care activities of aides. 

2. current efforts to i n outp ai ate care of the aged and chronicetlly 
ftUabled into the allied health curriculum are inadequate in view of the 
iapcrtatit iapact these ^tients will have on the health care delivery 


3. Oollaborative behavior aznong allied practiticners as %^1 as 
beti^aen allied health practiticners and other health care %rorkers is 
insufficiently prtnated by loanagenent in nursing hemes and hone care, and 
by education ixistitutiGns in the educational ea^erienoes provided to 

Education of Aides 

Passage of the prevision in the Qmibus Raccnciliaticn Act of 1987 
reqmiring a minlmim of 75 hours of initial aide training should nark the 
beginning of a long-reuige effort. Ocxitent to be covered in nurses aide 
training is to inclixSe basic nursing skills; persnnnl care skills; 
cognitive, behavioral, and social care; basic xestorative services; and 
resident's rights (U.S. House of R^iisentatives, 1987). 

Ihe ocnnittee views this training reguizenent as a reasonable 
starting point to raise the skills and knowledge of entry-level workers, 
who prov^ most of the direct patient care. Ihere is also an urgent 
need, however, for a visible pathway leading to hi^lher levels of educatia: 
for aides vho wish career p r o gr e s sion, and in pro v ed rEouneretion. Such a 
pathway into nureing or allied health fields would ccntribute to raising 
the Borsd and self-iinage of workere and ultimately reduce the costly 
turnover of personnel. 

In recognition that the greatest amount of direct nalient contact and 
care in lona-^^rm care settings and programs is provided bv personnel at 
the aide level, the federal govemmsnt and other responsible cpvemmental 
agencies should require education and training to raise the knowli^h? Nr\ 
skill levels of these personnel, Demonstratton projects should be ftmded 
to enoourage joint efforts bv educators and caggplovere in creati na v^^hio 
career patlg fgr fl1d?ffi 

Tolerance and coopathy with old, chronically ill, disabled, or 
demented patients is an elusive but critical attribute to be souglht among 
caregivers. Without this attribi:l:e, individuals are not liJoely to remain 
in long*-tem settings as a career. long-tem care aqployers and educators 
should identify and nurture those with this '^people-<»:iented'* attribute. 
Gne iqpproach be for enplcyuB and educators to develop local plans 
in which service in Icng-teim care settings would earn enpioyer-paid 
educational credits. Ihe credits could then be used by personnel to 
further their educational objectives. Such an investment would yield at 
least three desirable results: i np ro ve d quality of care for patients; 
ehhanoed recruitment of minorities, young people, «nd minimally fKtir^t^ 
individuals; > ^d, Jncxeased stability in the segment of the labor force 
providing di^rect care. Ihis approach would be particularly attractive if 
educational programs in the established allied health professions would 
reserve a small proportion of their entry positions (e.g. , 10 percent) for 
applicants from such Icng^-term care settings. 



- 18 

Other innovative ^ajiam jointly spcnsored by aoKiemic institutions, 
■uch as ocmunity colleges^ and oqployeiB ahculd also be oonsideied in 
canaating a career path. Ohe oonnittee was iapressed with the oono^ of 
art apprenticeship ncdel, iiiiich has had seme suoaess in the skilled trades, 
but has not reoeivied the attention it perh^ deserves in the health care 
fields, the nodel stresses on-the-job prac±ioal eoqperienae conlsined with 
fcmnal training. A key element in the siiooess of such a p rog ram is 
thatthe student-i#ariQerB' prospects for a '*good job" in tenos of pay and 
responsibility be rauarded at the end of the program. Ohese "good jobs" 
while not i>lentifui in today's long-tem care industry, nlst be developed 
in the decade ahead if the industry es^tects to ccniiete in tanorrow's labor 
narioet and ispcwe quality of service they provide. 

Dihancing The QirriculiiB 

Althoucfh allied health students gain technical esqpertise in areas> of 
oonoentration during their education, aary have only limited o^osure to 
chronically ill and disabled persons. Ihey may therefore hove only a 
superficial understanding of the ocnplexity of the physical, mental, 
emotional, and social problems of i]ii>aired persons and their families. 
Mien in training, allied health students may not rotate Itooicfh long-^tem 
care facilities or pi ngi ai u s to eaqperieme personally the technical 
difficulties in evaluating and caring for older or chronically disabled 

The cacBinittflP TwrmnwY^B tiv^i- nlHi^ >m\tt\ ff^y^tlcn and 
training proararos should include substantive content and practical 
Clinical experienoe in the care of the chronically ill and aaed . m 
general, such curricula should include information on the denogr at iiic 
shifts and changing epidemiological patterns of H^tumeaci and disabilities, 
the biological and psychological aspects of chronic illness and aging, the 
ocranon medical problens seen in patients, legal and ethical dilcmnas, the 
medical and psychological a^iects of death and dying, health prcnotion and 
disease and disability prevoition, interdisciplinary team participation, 
the evsQuation and assessnait of patent's needs, the roles of related 
health professionals, administration and management techniques, 
ocmiunication, and sipervisoiy eikills. 

Among these topics the need for assessgnent, pedagogical, and oopii^ 
skills particularly inprassed the oonnittee during its site visits. 
Because of ahortages or uneven distribution of allied health 
professionals, each of the allied health specialties may not ^« available 
to make an WBFirnmiwrit- of the patient from their own disciplinary 
perspective. Therefore, it is iaportant that all professional care 
providers acgoire knowledge that enables thou to make physical, 
psychological, and envizonmental nnnrnnaif iit of an individual patient and 
to develop an i^fxrcpriate plan of care. Ohey need this broader knowledge 
even thougfh sane of the needs of the patient may be outside the narrow 
area of ej^^rtise of a given allied health profession. Because allied 

Er|c 3r.: 

19 - 

health practitioners may be enployed as consultants having responsibility 
for a large iiaifcer of patients or residents, they nust also have the 
aikills to iistzuct addes ard family meDt>ers in activities in the plan of 
care and then be able to monitor the effectiveness and quality of the 
assistanoe given to patients. 

A major barrier to curriculum reform is the diortage of faodty 
ifiprapriately trained and e:9)erienoed in the care of the chronically ill 
and disabled. In an effort to ocobat deficienoes in the training of 
personnel and faculty, the Health Resouroes and Services Adninistration 
established regional resauroe centers throuc^h its Geriatric Education 
Centers p rogram. The program, which began in 1983, sugpports the 
Bultidisciplinary training of medical, dental, osteopathic, optonetric, 
pharmacy, pediatric, iwrsing, and allied health students, faculty, and 
others in geriatric health care. Other govemnental piujiai u s that have 
provided sultidisciplinary tredning include special project grants and the 
Area Health Education and Centers (also fe^wns o red by HRSA) , Long-Term Care 
Gerontology Centers (Administration on Aging) , and Geriatric Research, 
Education, ard ainical Centers (Veterans Administration) . Despite these 
prograns the National Institute on Aging task foroe estimates that the 
current noniser of faculty nesbers specializing in aging and geriatric care 
ranges frm 5 percent to 25 percent of the total nunter needed (National 
Ustitute on Aging, 1987) . A major focus for the faailty developnent 
grants recanoended in Oizqpter V should be enoouragenent of more faculty 
specializing in geriatric care. 

Orienting allied health education toward geriatric care %dll not make 
salaries mre ocopetitive, change the fact that patient care is physically 
and enotionally difficult, or Inprove working conditions. Ihe ccnmittee 
believes, however, that such education will help chose who do choose to 
work in these settings ranain longer by giving than the necessary 
knowledge and coping skills; it will increase the ^ Kxat unity for more 
students to consider the possible rewards of such a career; and it will 
encourage more faculty to engage in health services and clinical research 
relevant to the problems faced by long-term care providers. 

Imtt o v ed TeaoMork 

Ife have noted that the collaborative behavior in rehabilitation 
ho^itals is frequently absent in nursing hones and hone care. In the 
absence of financing inooitives that encourage teamMork, the rei^xxisi- 
bility rests with nanagers to organize their staffs in ways that maximize 
interaction among allied health practitioners and other caregivers. ISie 
axmittee, therefore, raooniDends that jT^TniyM* »k» prcblens afwnrfatwl with 
rfgmic illpo pf Hn not fall within the hmmrtarles of anv sliwle 
jjpr-j pHne, fiAntnistra tons and cage ooogdlnators in long-term care 
settings rfy jul ii develop effective means for ensiirina that all PerBcme3^ 
Involved in pffl^-^"^ care work cloeelv together to meet Patient needs. 


ERIC • , 

20 - 

Health caccB managers vculd be gzBatly assisted in these enSeavors if 
educators panovided the fcundaticn upon which collaborative behavior in 
later practioe oould be built. Allied health practitioners need to 
understani and appreciate the special ridlls and roles that their fellow 
allied health workers play along vlth the assets and limitations of others 
on the long-term care team. 

HhB issues of xecc\aitiBBnt, education, utilization of personnel, anl 
regulation raised tioDug^wut this report tate on a qpecial significance in 
the nation's struggle to achieve hiffliane care for its growing naiberB of 
elderly and chronically ill patients. Society will be under great 
pressure to aoocnnadate larger nunfcers of patients in the settings we have 
rt lsrufwed here. It will also be under at least as great pressure to limit 
the resouroes that mf be necessary to raise the standard of care. Allied 
health practitioners caugfht vp in this struggle will be challenged to use 
their ingenuity both on a personal level as care providers and 
collectively as an iaportant force for ahe^ing the care system. 

Ihe remedies suggested in this chapter are not new. Ihey can be 
found in the work of current comnittees and task farces and even in past 
Institute of Medicine studies on nursing and health care teams (IGM, 1972; 
lOM, 1983) . But the time to move teamwork and geriatric education ahead 
is long past due. 

No single reoc nu eiitotion the ccnnittee can devise will acoonpli^ 
this movecent. It must axe from health professions leaders willing to 
concede a measure of control and autoncny in favor of the oonmon goal of 
collaborative patient care. It will rec^iire the ingenuity of eduoatars in 
seeking additional resources for curriculum relorm or the resolve to 
initiate a painful process of res xscoe allocation that places a hi^(her 
value on collaboration and preparation for the 'jfnwmite of long^'term care. 



- 21 - 

American Health Care Assoclaticn. 1986. Nursing Hemes, A ScuroeboGk 
ftashingtcn, D.C.: American Health Care Assoc;5Ation. 

American Health Care Associaticn. 1985. Ttends and Strategies of Lcn^-^Itenr 
care. Haahingtcn, D.C. : American Health Care Asscxdiiticn. 

American Hoepital Associaticn. 1987. U^fiuialiflhed data from the Annual 
Ho^ital Survey and Survey of Rehabilitation Hospitals and Uhits. 
Chicago, 111. : American Hoqpital Association. 

American Riysical Iherapy Association. 1987. Active Meniaership Profile 
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Boehner, £. M. 1984. Kanaging to Achieve Quaility of Life. Background 
pqper prepared for ICH COmnittee on mprtvlng Quality in NUrsing 
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EtreKi3odc, D. 1988. "Challenges in Oonnunity Integration: in Integration 
of Developnentally Disabled Individuals into the Ckamunity. L. Healy, 
J. Harvey, and S.R. Novak, eds. Second Edition. Baltimore: BrooikBS 
Publishing a>. 

Btannon D., and Bodner, J. 1988. Ihe Primary care Givers: Aides and UMS. 
Mental Health Oonsultatior. in Nursing Homes. New York Uhiversity 
ftess. New York. 

Braun, S. Hospices for AUS cases: A Beginning " The Los Angeles Times, 
April 1, 1987:p. 1. 

oaifomia Association of Rehabilitation Facilities. 1987. Survey on 
Rehab MarpcMer, UhpUblished data. California Association of 
Rehabilitation fteilities (Deoenber) . 

OK-.ters for Disease Oontrol. 1987a. AIDS Weekly Surveillanoe Report. 
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Infections in the U.S. : A Reviev of current RxMledge and Plais for 
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SdiDonds, L., and L. James. 1984. Tenporal Tkends in the Ihcidenoe of 
M&lfatmation in the Uiited States, 1970-71, 1982-83. Hoirbidity and 
Mortality Meekly Review. Vol. 34, No. 255. 

Bigland, B. et al. 1987. An Agenda for Medical Rehabilitation, 1987 and 
Into the 21st Century. Americun Ho^ital Association. Unpublished. 


- 22 - 

Federal Register. October 16, 1987. U.S. Federal Register, Vol. 52, 
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Health and Riblic RDlicy Ooradttee, American College of Riysicians. 1986. 
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Institute of Medicine. 1972. Bducaticn for the Health Team. National 
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Institute of Medicine. 1983. Nursing and NOzsing Bducation. Rablic 
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lUhl, A. , Bureau of labor Statistics. Benarks at a synposium on nurses aid 
training, Ncvenber 1987. National Citizens Qoalitlcn on Nursing Hone 

Kane, R. L., md Kane, R. A. 1982. Valiies and lang^-^rerm Care. Lexington, 
Mass.: Lexington Books. 

Kereciiner, P. 1987. Staffing: Getting the Edge on McDonald's and Pizza 
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Lesparxe, M. 1987. **ParadQOfies of Medical Rehabilitation, in Perq)ectives, 
a sifplenent to Medicine and Health. NGvenber 16. Nev York: 

Lsvine, I. and Fleming M. 1986. Human Resources Development: Issues in 
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Long Tern Gare Managenent, 1988. **Aids: Nhat Role for NOrsing Hones?**. 
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Govemnent Printing Office. 



- 23 - 

March of Wnes. 1987. Birth Defects, Tragedy and Ifcpe. Wdte Plaines, 
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HEdtzer, J. , F. Farrow, aixJ H. Richnan. 1981. Policy Options in Long-JTenn 
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Mnlinger, M. Home Gare Oontroversy. 1983. Rocik^dlle, Md.: Aspen 
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Public Lbw 99-129, Signed October 22, 1985 

Sec. 223(a) (1) Ihe Secretary of Health and naan Sendees shall 
arrange for the OGnduct of a stud/ cacnoemixig the role of allied health 
perBGnnel in heelth care delivery. Ihe Secretary ihall request the 
N&ticnal Acadera/ of Sciences to conduct the study under an amngenent 
under ^dtddti the actual expenses incurred ly the Aoaden/ in ocnducting such 
stud/ %dll be paid by the Secretary and the Aoads:/ will prepare the 
report required by subsection (c) • If the Itaticnal, Acadeny of Sciences is 
willing to do so, the Secretary shall enter into such an arrangement %iith 
the Acadeni/ for the conduct of the stud/. 

(2) If the National Aadeny of Sci&ioes is unwillingr to conduct the 
stud/ required by paragraph (1) lader the type of arrangement (&»scribad in 
such paragraph, the Secretary shall enter into a similar arrangement with 
one or more appropriate nonprofit private entities. 

(b) Tne study required by subsection (a) shall : 

(1) assess the role of allied health personnel in health 
care delivery; 

(2) identify projec t ed needs, availability, and require* 
ments of various types of health care delivery syrcens 
for each type of allied health personnel; 

(3) investigate current practices under which each type 

of allied health personnel obtain licenses, credentials 
and accreditaticn; 

(4) agflocs changes in programs and curricula for the education 
of allied personnel and in the delivery of services by 
such personnel vhich are necessary to meet the needs and 
requirements identified pursuant to paragr ap h (2) ; and 

(5) aooooo the role of the ^Federal, State, and local govern- 
vents educational institutions and health care facilities 
in meeting the ne^ds and requirements identified pursuant 
to par«igr8qph (2) • 


(c) By Octd3«r 1, 1987, thb Sacxvtaxy of Hwdth and Houn Sexvices 
ihall t rann lt to tte oamittee cn labor and HUnan RMouxoes of the Senate 
and the Gcnnittee cn Bwrgy and GBnneroe of the Hcxne of Rgpgnoontativjs, 
and aake availaiala to the public, a xnpoKt: 

(1) daecribing the study oondiiBted under this aectlon; 

(2) «.cntaining a Ktatcnan^. of the data obtained mler such 
study; and, 

(3) specifying such racxanendaticns for legislation and 
adb&inistiative action as the Secxetary considers apprapriate. 

ERIC * ^ 



vnancimrrs of mcrkshsps ahd »jb£JC meetinss 





July 1, 1987 

American Assoc. of Oertifiod Allied Health Fersomel in OphthalmDlogy 
Momia GariDer 

American Assoc. of Oertified Allied Health Pezscnnel in CphthaLnology 
Elle RnFMimut tiuiijan 

American Associaticn for Marriage and ftedly Ihsrapy 
Michael Bowers 

American Association for Respiratory C&xe 

Mel Meu±in 


American Association of "Certified Qrthcptists 
Barbara Chassin 

American Association of Oertified Orthoptists 

Randy Goutennan 


American AssociatiGn of Medical Assistants, Inc. 
Don Balasa 
Assistant Director 

American Cardiology ^Technologists Association 

Stephen Kaniedd 


Ai cican Cardiology Technologists Association 
lin^. i HuDStcn 

American Obllege of Cardiology 
Itancis J. Nenapaoe, Jr., M.D. 

American College of MUrse-Midwives 
Khren Boderiiom 

American College of Radiology 
Marie Zinninger 

American College of Radiology 
Mark Mishkin, M.D. 
Ccnmittae on Hunan Relations 



Anerican ODllege of Radiology 
RoiDezt Bnden 

Anerican OoHlege of Surgeons 
CinE3y Brown 
ftodiingtcn Associate 

American Dental Association 

Louis Schuhrloe 

Council on Dental Education 

American Dental Association 
Brenda Hazriscn 

DixBCtor, State Govemnent Affairs 

American Dental Association 
L.P« fteat 

Director, Govemnent Relations 

American Dental Association 
J. O'Donnell 

Director, Legislative Policy 

American Dental Hygienists Association 
William Schmidt 

American Dental Hvr^ienists Association 
Diane de Root, cassage 
Second Vice President 

American Dietetic Association 
Jean MLiskoff 

American Dietetic Association 
Patti Blumer 

American Dietetic Association 
Bob Earl 

Manager, Govemnent Affedrs 

American Hospital Association 
Barabara Xkwl 

Director, Hiaan Nations , 

American Medical Record Association 
Rita Finngegan 
Executive Director 


Xnexican Madical T^adinologists 
Willian WtbixiB 
Board of DirectorB 

Ainerican Madical I\Bchnologists 
Eleanor Bora 
Exacutlve Diractor 

American Oocqpational Hherspif Association 
Susan Scott 

Diractor of Gcn/emnent and legal Aff edxs 

Ansrican Oocqpational Iherapy Association 
Stqphanie Hcxiver, Ri.D. 

American Ocxqpational Therapy Association 
Jeanette Bair 
Diractor, n:BCtloe 

Amerian Orthotic And Aesthetic Association 

General William NoCullodi 


American Orthotic And Rnosthetic Association 
Charles Unger 
Director, MXk Affairs 

American Orthotic and Rnosthetic Association 
Wilson latlQcvic 
Assistant Director 

American Rxysical Therapy Association 
Itahk Mallon 

Associate Executive Vice Rnesident, i^ofessional Relations 

American Riysical Iherapy Association 
Tom Welsh 

Chief, Riysical Ihereqpy 

American Society for Medical Technology 
Glenda PrioB, Ri.D. 

American Society for Hedical Technology 
Sidney Oliver 

American Society far Itemtiaral and literal Nutrition 
Janet Gannon 

Director of I%ofessional Developnent 

Aioerican Society for Medical Technologists 
Ij/m Podell, J.D. 
DcBcutive Oirector 

Jkmerican Society of Allied Health Ftofessions 
David Broski, Ri.D. 

Anerican Society of Allied Health Kofessions 
Pat Gillespie 

American Society cf Clinlcial Pathologists 

Paxil Chemey, M.D. 

Chaiznan, ASCP Board of Registry 

American Society of Clinical Pathologists 
Cathy Cdhen 

American Society of Clinical Pathologists 
Barabara C&stlebem/, Ih.D. 
Vice President 

American Society of Qiniced Pathologists 
Boiabi-lynn ftotnik 
Legislative Assistant 

American Society of Cytology 
Ann H. dark 

Prof, of cytotechnology, M.U.S.C. 

American Society of cytology 
Sally-Beth Budcner 

American Society of Electrcneurodiagnostic Technologists 
Lei^ O'Neal 
Board of TrvE/tBB% 

American Society of Microbiology 
Dieter Groeschel, M.Dr 

Chaiman, Ocmdttee on laboratory I^ractioes for Microbiology 

American ^Mch-Iiuigiuage-HBaring Association 
Morgan Downey 

Amerioan %)eechrUmguage-iiaaring Association 
Janes lingwaU 

Association of Surgical Tedmologists, Inc. 
Barteza Gay 

Association of Surgical Vachnologists, Inc. 
NiUian Teutsdi 

Bursau of Utac Statistics, U.S. Department of labor 

Ann Kehl 


American Association of Bioanalysts 
Don lavanty 
Govemnent Relations 

Oongrassional Research Service 

Janet Kline 

Chief, Health Section 

Gini Associates 
Eugenia Carpenter 

Greater Soutteast Qexnunity Hoqpital 

IhcBoas Chapnan 


Greater Southeast Ocnnunity Hospital 
Hichale Johraon 
Administrative Fellov 

Health Gere Financing Administration, U.S. EHHS 
Stanley E. Bdinger, Ri.D. 
Scienoe Director 

Health Resouroes and Services Administration, U.S. EHHS 
Jerry Hcdenkn 

Rational Board of Cardiovascular Tasting, Inc. 
carol Rabbins 

Natlcnal Board of C&rdiovascular Testing, inc. 
Diana Gunther 

National Coalition for Arts Oierapy Associations 

Janes Mitchell 


National Qondssion for Health Oertif ication Agencies 
Barbara Hickey 

National Hearing Aid Society 

Tinothy Maters 


National Society for CBantiiopulmonary !Dechnology 
Michael R. Boivin 

National Society of Allied Health 

Barley nack, Hi.D. 


Office of the Assistant Secretary for Planning and Evalxoation, U.S. EHHS 
Herbert C. Hamnond 
Poli^ Analyst 

Office of the Assistant Secretary fur Health, U.S. EHHS 

Cbrol Zucket 

Senior nnogram Analyst 

Society of hliclear Medicine, Technologist Section 

Marcia Boyd 


Society of NUclear Medicine, Technologist Section 
Rtul Cole 

Society of Nuclear Medicine, Technologist Section 

Virginia Peippas 

D^ty E}CBCutive Director 

Virginia Citizens Ocsnsumer Council 
Helen Savage 

Virginia Department of Health Regulatory Boards 
Richard Morrison 



Wane NOoen, Director, Health Affairs Division, Texas Hic(her 

Education Ooardinating Boaxd 
Fttul Ramix^z, Dean, Health & Public Services Occupations, El Paso 

OoDunity Oollcge 

John Bruhn, Dean, School of Allied Health, Uiivexsity of ?^exas Medical 

Bnnch, Galveston 
Leo SeUcer, Assistant to President, Texas Monen's Uhiversit?^ 


Roderick T. GEoves, Chancellor, Illinois Boaxd of Regents 
C:r,id Btoski, Dean, College of Asso c iated Health Professions 
Richard TuacO^, Dean, Health Services Institute, City Colleges of Qiicago 
Robert A. Kallhaiis, Deputy Director for Acadanic Affairs, Board of Higher 

Aztii lugerteel. Dean, T^^ident Technical College, Charleston, South 
Carolina (Fomerly at Southern Illinois University) 

MEW ray 

Ednind Mc^teman, Dean, State University of New York, Stony Brook 

Souther Baines, State university of New York 

Edwrzd Salsberg, Director Bureau of Health Resources Developnent, 

Hew York State Health Department 
Leroy Sparks, Vm York City Techncial College - Brooklyn 

Other Guests 

Gerry Ktoniraki, Dean, Health Technologies Div., Cincinnati Techn. Oolloge 
Dr. Catherine B. JUnge, U.S. Dqparbnent of Education 
Dr. Allan W. Ostar, President, American Association of State Colleges 
and Universities 

Dr. a\illio Altartini, Health Rasouroes & Serivoes Administration, US EH»5 

insttiuit; of medicine 

aiMrnxE to smcv ohe bole of aiijed heaihh ierscnnel 

Wbrlcshcjp on Rwrtors That Affect the Demand far Allied Health PBTSocmel 

April 26 - 27, 1987 

Seynour Fteny, MD. , Prof, of Hedidne, Deputy Director, The institute for 
Heedth Poliq^ Analysis, Georgetown Uhivesity Medical C3enter, 
Washington, D.C. 

NOnnan F. Bstrin, Hi.D. , Resident, Scienca and Technology, Health 
Industry Manufacturing Association 

tomi Chemoff , Ri.D. , RD, Assoc. Director of Gf riatric Research, 
Education ard Clinical Center for Education 'u^d Evaluation, VA 
Medical Center, Little Roclc, Arkansas 

Stanely B. Jones, Vice President, Consolidated Health Care, Inc. 

Cherlyn S. Granrose, Ih.D. , Assistant Prof, Departanent of Human Resources 
Administration, Teqple tftiiversity 

Dereiis J. Treat, OU, Director, Washington, D.C. Group Operations, The 
prudential Life In^jranoe Conpany of America 

Richard Schmidt, Scenlon. l^Iastings and Schmidt 

lAird Miller, Health AoTtagenent Systems 

Brent England, MS, Directxir, Section for Rdiabilitation Hospitals and 
Programs, American Ho^ital Association 

Charles Hoetetter, MD, Deputy Director, AIDS Services Program, HRSA 

Reith WfeUcel, Ph.D. , Dcecutive Vice President, Health Care and Retirement 
Corporation of America 

Ifartha Hopler, Director of Human Rasouroes, Medlantic Health Care Grxxp 

Donald Jackson, MD, FT, President, Rehabilitation Systems of Illinois 



Appendix HI 



A Sanple of Allied Haedth Jcb TiUes 
(Mten fmn the Heu York City Health and Hospital Ootportation) 

Clinical Labaratoty Technology 

AsKKiate lAboratory Micxcbiologist 
Chaodst (BiochendstKy) 
laboratory Associate 
laboratory Micxtsbiologist 
laboratory Technician 
Principal Microbiologist 

Dental Services 

Dental Assistant 
Dental Hygienist 

Dietetic Services 

Assistant Director of Food Service 
Associate Si^ervising Dietitian 
Chief Dietitian 
Dietary Aide 

li^rsjngency Nadical Servicses 

Aidxilanoe Technician 
Aslaulatary care Technician 
Bnargency Medical Service Specialist 

Nadical Raoord Services 

Assistant Director of Medical Racords 
Assistant Director, Medical Records Services 
Associate Medical Record Specialist 
Medical Raoord (Specialist 
Senior Medical Records SysteoB Analyst 


Ocxi^tional Iherapy 

Ooaapationl Ohere^ist 
Itiysical Sierapy 

Physical lhe3:z^lst 

Radiological Seivioes 

NUdear Nadlcine Technician 
Radiation Technician 

Re^iratoiry Therapy 

Re^iratory Then^ist 
Re^iratory Therapy Technician 

Speech-Language I^thology/Audiology 

Audiology Clinician 
S^^eech Clinician 
Staff ALdiologist 
Staff Speech Pathologist 


Addiction Counselor 

Addiction Specialist 

Assistant Addiction Counselor 

Assistant Bio-Medical Ecjuipnent Technician 

Assistant Oonnunity Liaison Worioer 

Assistant Supen^isor of Recxeation 

Bio-Medical Equipment Technician 

Electxooardiognph Technician 

Elect r o e noephalograph Technician 

Medical Egfuipnent %)ecialist 

Operating Room Technician 


R^ician Assistant 

n^chiatrlc Social Health Technician 

Rdiabilitation Counselor 

Rehabilitation Technician 

Senior Electrocardiograph Technician 

A Classif icatlGn of Instmcrticnal I^ogranB ;ciP) 
in AUied Health 

The Classif icatlcn of mstmcticnal Frcgaats (OP) , dsvelqped by the 
U.S. Departamt cf Edbcaticn's Center fcr Eaxaticnal Statistics (CES) in 
1979-80, %ias \;qpdated for the first tine in 19b5. OP is a taxonGn/ for 
instnictual pLujiam at all levels. It is used in all CES surveys and is 
the aooGpted govemnent standard far education infomation surveys. 


17.01 Dental Services 

17.0101 Dental Assisting 

17.0102 Dental Hygiene 

17.0103 Dental Laboratory Technology 
17.0199 Dental Services, Other 

17.02 Diagnostic and Tkeatnent Services 

17.0201 cardiovascular Technology 

17.0202 Dialysis Technology 

17.0203 Electrocardiogn^ Technology 

17.0204 Electroenoephalogr^ Technology 

17.0205 Bonergenc^ Medical Technology - Anbulanoe 

17.0206 Etergency Medical Technology - Ita^i^c 

17.0207 Medical Radiation Dosiiietry 

17.0208 Nuclear Medical Technology 

17.0209 RBdidogic (Medical) Technology 

17.0210 Respiratory Iheraiy Technology 

17.0211 Surgical Tectoology 

17.0212 Diagnostic Medical Scnography 

17.0299 Diagnostic and tteatment Services, Other 

17.03 Medical Laboratory Technologies 

17.0301 Blood Bank Technology 

17.0302 Chonistxy Technology 

17.0303 Clinical Anijoal Technology 

17.0304 Qinical Laboratory Aide 

17.0305 Clinioal Labaratory Assisting 

17 . 0306 cytotechnology 

17.0307 Hematology Technology 

17.0308 Histologic Technology 

17.0309 Medical laboratory Technology 

17.0310 Medical Technology 

17.0311 Microbiology Technology 

Q 17.0399 Medical laboratory Ttechnologies, Other 


17.04 Mental HeedttVIftiian ServioM 


17.0401 Alcsohol/Dcug Abuse Specialty 

17.0402 Oonrunity Health Mark 

17.0404 Hone Health Aide 

17.0405 Mental HealtVHwan Sexvicses Assisting 

17.0406 Mental HealtlVHunan Servioae Technology 

17.0407 Rehabilitation OGunseling 

17.0408 Therapeutic Child Cere Nock 

17.0409 Papulation and Ftedly Flaming 

17.0410 Sign language Ihterpnting 
17.0499 Mental HealtVHonan Sedves, Other 

17.05 Misoellaneous Allied Health Services 

17.0502 central Supply Technology 

17.0503 Madinal Assisting 

17.0504 Medical lUustxating 

17.0505 Medical Office Manageoient 

17.0506 Medical Records Technology 

17.0507 fhaxnacy Assisting 

17.0508 Riysician Assisting 
17.0510 Rodiatric Assisting 

17.0512 Veterinarian Assisting 

17.0513 Health Uiit Qoordinating 

17.0514 Chiropractic Assisting 

17.0599 Miscellaneous Allied Health Ser^^ices, Other 

17.06 Nursing-Related Services 

17.0601 Geriatric Aide 

17.0602 Nursing Assisting 

17.0605 Fkactical Nursing 

17.0606 Health Unit Managenent 
17.0699 Nursing-Related Serviceet, Other 

17.07 Ophthalmic Sendees 

17.0701 Ophthalmic Dispensing 
17.0705 Gptcmetric Technology 
17.0799 Ophthalmic Sezvioes, other 

17.08 Rehabilitation Sendees 

17.0801 Art Therapy 

17.0802 Oorrective Therapy 

17.0803 Dance Ther^sy 

17.0804 Exercise Riysiology 

17.0806 Music Then^ 

17.0807 Ooaqpaticnal Therapy 

17.0808 Ooo^tional Therapy Assisting 

17.0609 Onniwtlcanal Ohexapy Aide 

17.0611 OrthotlcB/Pixsthstics 

17.0612 ^IrthBpedic Anisting 

17.0613 Rxysioed 'Ornate 

17.0614 RvBi«l nwnqpy Aide 

17.0615 Iti(yiioel Ohainpy Assisting 

17.0616 Recxaational Ohezapy 

17.0617 Recxwtion llMKnqpy Assisting 

17.0618 RMpiratory Ttma^ 

17.0619 RMpixatocy Ihsnqpy Assisting 

17.0620 fltMdVHearlng Ohen^ Aide 
\7.C622 Itereatlcnal Ihexapy Aide 
17.0699 Rahabilitation Snvioes, Other 

17.99 A:ilied Health, Other 

17.9999 AUied Health, Other 

ERIC 390 

AffMndix IV 


Making an yxairste OTWfimwnt of the wcf.^ \ ot allied health 
practitiav>n. in eacii field is not eas/. For aary fields, no reliable 
data aouzus aodsts for either ttm total naiaer of qualified people, the 
ludaer vorldng or the xtjober not woridncr taut available if the ric^ larket 
oonditicra occur. Ibe Bureau of labor Statistics (BIS) U86s the 
Ooa^ticnal Boplcynant Survey ((IS) , vhich collects data en the nunfcer o: 
filled jdas. in fields %dth a hic^ incidanoe of mltiple job holding BLS 
data at* an Inaocuarate reflection of the labor faroe. Another aajor 
source of data, tt» daoemial census of the Qiited States, was last 
ocnductsd in 1980; these data, are now dated, and their definiticns of 
allied health fields oftm do not aatch the professions' definitions. A 
third source of data, professional associations' nenberships, nay 
oTTHao cnly a mnUl ftaction of the siqpply of practioners. Sinoe not 
all practitioners are listed as certificate, license, cr registration 
holders and not all listed practitioners are in the active labor force, 
these also are not alvoys accurate representations of the labor foroe. 

Nevertheless, some estlaates of the sqpply of practitioners c an be 
nade. For eoornple, in fields vhere nultlple-job-holderB are not occuGn, 
the BIS data ulosely approodinates the nunber of peq;>le woridng in the 
field. Some proftesional asuociations collect data en both the nunber of 
qualified practitioners and the naiber of practitioners active in the 
field.This appendix presents supply estlaates derived fion varia^ souroe- 
of data. Thx^ it is difficult to plii»int a "best figure," the 
estinates can be used to mp a reasonable 2»nge of the nober of people 
working in sach of 10 fields. 

1. rlgtitintr* 

FTP estinatad total eDployment dieticJm a in 1986 to be 40,201 
(38,201 wage and salary and 2,000 self-«nplcyed dietitians) . Ihe iHS 
defines distitlara as people v!x> "organize, plin, and conduct food service 
or nutritional piuyta u s to assist in [the] prcmoLlon of health and control 
of disease." Dietitiam "ney adninister activities of a departanent 
providing quantity food service", and "nay plan, organize, and conduct 
prograns in nitrltional research." 

Ihe American Hospital Assoclatioi.-s 1985 anraal survey indicated that 
there %iexB T %993 full- and part-tine dietitians cnplcyed in U.S. 
registered U^picals th»t year. BES estisates that 37 percent of all 
dietitians wure aployeu in hospitals in 1986. Assuming that the nater 
of dietitians working in hospitals did not change significantly between 
1985 and 1986 WB8 ra#ily equal to AHA's 1985, thm extrapolating trm ttie 


MA data (14, 933/. 37) , ve estioate that there were about 40,100 distitians 
eqplcyad in 1986.— oonfindng the BL5 astinate. 

Ihe Anarlcan Dietetic Association zvpoztad 44,570 registered active 
dietitians ait thB end of 1987. 

2. Dental Hvaleniefea 

the ces defines dental hygienists as people «ho ' ^fui ia dental 
prophylactic treatnents and Instruct groins and indiviAials in the care of 
the teeth and nouth.** BLS eatinated that dmtal hygienlst filled 86,676 
jobs in 1987— none %wr» self en{>Ioyed. As BMitionad earlier, the BLS data 
jsertains to jobs. People idho hold van than one job are counted at each 
job site. Because nultiple job holding is omun among dental hygienists, 
the nailer of dental hygienist jobs filled greatly eoooeedta the ruiber of 
iKirking dental Ixygianists. 

Ihe Bureau of Health Itefesk^ions of the Health Pasouroes and Services 
Administration estimate that there were 45,800 dental hygicnists in 1984 
filling an estimated 76,000 jOis. Ohus each working hygients filled an 
average of 1.66 jobs. Assuming the job to hygienist ratio was about the 
same in 1986 as in 1984, vb estimate that there were atxxit 52,200 woridng 
hygienists in 1986. 

Dental hygienists are licensed in every state and the District of 
Oolmbia. To obtain a license, a candidate graduate from a dental hygiene 
achoca accredited by the Ocmnission cn Dental Accreditation and pass both 
a written and a clinical examination. According to the Ocnmissi in'o 
1986/87 annual report, a total of 51,713 students graduated fron 
accredited sdvaris bsts^ssn 1976 and 1986. 

3. ni^Ttjp^ HiwIIctI Tfrtimiffiflnff 

BLS estimates that there were 65,229 paid eDezgency medical 
technicians (EMDs) in 1986. EMTs, aocxsding to the OES survey instrument, 
"administer first aid tiea UuanL and transport side or injured persons to 
medical facilities, wocking as a moober of an energency medical team." 
BfTs are not anbulanue attendants and drivers. 

Sinoe there are many volunteer BOm ttm nsober of paid aos 
understates the true supply of practitioners. Qie 1985 Hotional IMS 
Clearinc^uuse survey indicated that approadaately 95,000 SfTe are 
certified lonually in 42 states. New York, Ttoas and California, three of 
the most populous States, were not among those reparting. cstrtif ioaticn 
is generally valid for tMo years; %n tharefore estimate that there axe at 
least 200,000 certified BC^ in the U.S. in ary one year. 

4. Medical lebcgatoev 'DMAnolonlgfce and Taehnielane 

BLS estimates that 239, 350 jobs existed for medical laboratary 
technologists and technicians in 1986 including 1,000 self-enployed 
persons. Ohe CES defines medical and clinical laboratoxy technologists as 

- 3 - 

paopl« \ix> "perf ocn a vide range of csoplex p rooa3 u res in the genexzd 
axeas of the clinical laborataty or perl onn qpeclallzed procedures in such 
areas as cytology, histology, and idcrjblology." Their "duties nay 
include sicwxvislng and ooordinating activities of wackerB engaged in 
laboratory testing and include workers who teadi nadical technology when 
teaching is not their prioary activity." Nadlcal and clinical laboratory 
technician are defined as persons who i^perf am routine tests in nedlcal 
laboratorlefi for use in U e ati u Mit and diagnosis ef disease." The/ 
•^pnpare vaccines, blologlcals, and senns toe prevcntlcn of disease" and 
"prepare tissue sanpies for pathologists, take blood sani>les, and execute 
such laboratoocy tests as urinalysis and blood counts." Laboratory 
technicians "nay votk inder the gMiaxal sqpervisicn of a nedlcal 
laboratory tachnologLst." Althoug|ti BIS collects seperate data for the tw^ 
categories of laboratory persomel, the data is ocnbined for reporting 

It is difficult to estlDBte the average ratio of technologists to 
technlciaiv. Of the 209,000 registrants of the Anercdan Society of 
Qinical Bftthologlsts 82 percent %pere nedlcal technologist in 1987. The 
xeglstaxy of the Itatlcnal OertlflGatlon Jhgency for Madical laboratory 
I^rsomel was CTnyr^ff^ of 83 percent technologists and 17 percent 
technicians in Saptenfcer 1987. If the above ratios are applied to the ELS 
estiaate of total enploynent of nedlcal laboratory technologists and 
technicians, the nxrioers of technologists and technicians in the workforoe 
in 1986 waild ?iBve bean about 196,267 and 43,083 respectively. A word of 
caution. 'Mchnlcians nay be less liloely than ^3chnologists to be 
certiflei, thus cur estinate nay xnderxepresent technicians and 
overxepresent technologists. Uhfartunat&Ly, ttieem is no easy way to 
verify the ratio of tedinlc'ans to technologist.. 

5. MadJcal Beoopa MndnlstratorB and Ttechnicjiang 

EES does not estinate total eDploynent for nedlcal record 
administrators (MRAs). 

The AHA 1985 annual survoy ^kws 7,639 full- and part-tine nedlcal 
xeoOiA administratars cn()layed in U.S. registered hospitals in that year. 
If, as indicated by ttm Aonericaii Record Association (AMRA) 1986 neniaership 
survey, miroKlirBtely 73 percent of all MRAs wocT: in acute care faclli1:les 
then (esetrtgpolating trm the AH^ data) the total nnter of persons 
•iiplayed as nadioal record efiuunliBtaAaeB 'ciould be 10,464. If this is the 
case over 20 percent of perpie filling MRA jdss are unregistered since 
AMRA reported only 8,240 registered nedl(3l record odministatars in 1987. 

m^lo/oBrtt of nedlcal record technicians (MRT) was estinated by EES to 
be 39,888 in 1P86. The OES survey, defines MFTb as persons «ho "ccnpile 
aid anintain i iM^"*'' reoocdt^ of bio^ltal and clinic patients." AMRA 
zeported 14,690 accredited record technicians (ARDe) in 1987. 

ERIC ' ' 

- 4 - 

The KJK 1985 amual survey itews 43,383 full- and part-^tiae 
raocaxl tedmlclanB aii>layad in U.S. ngisteced hospitals. Ihis is not only 
substantially hi^fher than the BIS astinate of 24,500 jdbs in hospitals, 
l3ut also hlg^ than the BL6 sstinata of total techniciam' joias in all 
settings. Vie xvasons for this diffemoe is uriknown hit my be saic(ht in 
an eKandnaticn of the %ieys in which jcb definitiora axe developed, and 
intezpreted hy survey zei^nidents. 

Ihe BIS estiaates that 29,355 jdas fbr ooa^aticnal thenqpists eidsted 
in 1985. Ihe GES defines ooaqaticsnal therapists as persora vho "plan, 
organize, and pa r ti c ipa t e in nedically oriented ooo^pational ptujiam in 
hospitals or similar institutions to rehabilitate patiaits «ho are 
physically or noitally ill." 

Ihe MA 1985 amual survey shows 10,595 ftill- and part-tine 
occupational therapists cnctloyed in U.S. registered hospitals, ihe 
TVoerican Ooaqpational Thereby Association (Kym) reports that about 28 
peroent of its nenbers wortod in general and pediatric hcapitals in 1986. 
ELS estimates that 32.5 peroent of total cnplo/nent is in ho^itals. 

Tttal active menbership of registered occupatioml ther^ists in the 
Mm. Has about 27,300 at the end of 1987. Ukitil Did-1987 registered 
occupational therapists autcnatically became menbers of the AOIA, and the 
tally of active menbers represented about 99 peroent of the prttfessicnal 
workforoe. Menbership in the associatiCii is nov voluntary. 

7. Rwaical Theraplsta 

Total enployment of physical thengpists in 1986 vaa estiaated by ELS 
to be about 61,168, including 5,000 self-^enployed persons. Ohe OGS 
defines physical therapists as persons «ho "aqpply techniques and 
treatments that Nelp relieve pain, incree 3 the patient's strength, and 
decrease or prevent oefonnity and crippling." 

Ihe American Riysical Ohet^ Association (APIA) estiaated the naftier 
of licensed physical therapists to be 65,890 as of JUne 1986. All states 
require practicing professional physical thenpists to be licensed. 

8a. RwHolmlc Tachnologista and Ttechnleiiinfl 

Ihe BES estiaates that 115,429 jobs for radiologic tKhmlogists ani 
technicians axistad 1986. Ihe GGS defines radiologic technologists as 
parsons who "take x-rays, cat scans, or adhninister non-xadioactive 
materials into patient's blood stream for diagnostic and th r^ieutic! 
purposes." Hospitals wre asked to include in the category of radiologic 
technologist workacs vhose primary duties were to demonBtrate poctiom of 
the hunan bod/ on x-ray film or fluoroscopic scxeera. Radiologic 
technicians were defined as parsors «ho rnaintain tni safely use eqo^me^ 


- 5 - 

and wqpplifls naoessary to donanfttxate portions of the human body on x-ray 
film or a fluoranopic acnan '^ur diaonostlc purposes." Incduded in the 
BLS "rwliologic tachnologists .iid tadinlcians** oatagocy are radiaticxi 
therapists and sonographers. NUdsar Badicine technicians are not 

Ihe Bureau of Health Itofessions estlxatss that there %fere 143,000 
radiologic health sexvioe wortens of all types in 1986, including nuclear 
Btddidne technologists. 

8b. HiI7'''W^ Ka dieijie Ttedmoloaists 

MUdear nadicine technblogists "prepartt, aAninister, and measure 
radioactive isotopes in therapeutic, diagnostic, and tracer studies 
utilizii'jg a variety of radioisotope egaipaent." Obey "prepare stock 
sdutiora of radioactive naterlals and calculate doses to be aAninistered 
by radiologists." They "subject patients to radiation [and] eooecute blood 
volume, red survival and fat cteooption studies following standard 
labccatory technli]ues.'* 

BLS estimates that there ware 9,677 nuclear nadicine technologist jobc 
in 1986, aC which 89 percent ^mre in hospitals. Over 88 percent of Hie 
respatOerttB to a 1987 survey conducted by the NUdear Madlcine Technology 
Oertificatior Board indicated that they work in a hoepltal. 

Ite 1985 MA survey of U.S. hoepltal indicated that there were 7,972 
full- and part-tine nidear medicine techndoglsts enployed in U.S. 
registered hospitals in that year. If about 89 percent of t>ll nudear 
madlcine technologists vork in hoepitals, the MA data sugget;ts that the 
total nunber of nadear mBdldne techndoglsts enployed in 1985 was abcut 
9,000, which is dose a yxeauaiT t with the BIS estimate. The ¥Mr 
Oertlflcation Board reported 10,298 certified ter^vidoglsts in Aujust 

9. aasDimtprv TheraDlsts 

BIS estiaated that 56,333 jobs for respiratory therqplsts existed in 
X986 — there %«re no sdf enployed re^lratoiry therapists. Ihe OES 
defines respiratory therzqpists as persons who "set up and operate varlcus 
types of egoipnent, such as iron lungs, oo^gen tents, rasuscitatars, and 
incubators, to adblnlster coeygen and other gases to patients." 

Ihe 1985 MA survey indicated that there were 32,623 respiratory 
thenpists enployed in US registered hospitals in that year. The American 
Association for Respiratory Care (AARC) states that the majority of 
re^lratory care practitioners work in hoqpltals. BUS estimates that 88 
percent of such jobs are to be found in hoqpitals. 

- 6 - 

10. finRwrh mthnlmlgta and 

Ihe BLB •BtLntas that jdas far qpaach pathologlsta and audiologlsts 
nnterad 45,129 in 1986, inclUfUng 3,000 aalf-^iplcyKl pcactlticnezs. Ihe 
CIS aurviiy daf ined qpaadi pathOlogiBta and audiologiats as health can 
prBCtiticmcs iJho "aKanina and provida zamedial ■ervioes far paracm %dth 
apBeA and hMBring diaocdan and perf ocn imcmii It ralatad to armnrti and 
languaga prablaDas." 

lha 1985 MA aurvay idmtifiad 5,354 ifiaach pathalogiats and 
audlologists oi^ Icyad in 15 ragistara) hoapitaU in that yaar. If, as the 
BIS statos, hoepltals pEOvida cnly about Un perosnt of total «(>loyiaent 
for speech pathologists and audiologists the total naber of ipeech 
pathologisU and audidlogists aaplcyttd in 1985 would havtt been About 
53,540— substantially highar than the BLB astisata 

56,287 qpeach pathologists and audlologists are certified by The 
American ^aech-Ianguaga-Hearing Association. Ninety^two peroent of 
certified practitionera, are ASHA aodben. Although basic ocopaticnal 
pr^xuration is at the aaster's level, persons haHdirts cnly a bachelor's 
decpnee in qpeech pathology and audiology are «0DplGyed in some settings and 
aay be conaidered a part of the labor simply. There is no estlaate how 
aany bachslor's-level practitionerB exist. 



^Appeniix V 


Hhis BspperObc descrUbes the purposes fcxr lyhich priojectiGns of demand 
and mjppLy of wkBCB an made and the characteristios these prpjecticns 
aysu hove if ths/ are to serve their purpose. The various nethods that 
have been used for sakinr} pcojections are suBoarised and the limitations 
of each is Hlanisiwl. ihe aocuracy and linitaticm of the methods tsed by 
the Bureau of labor Sta^^stics are discussed. A final section points to 
needed ii i uMau . fi needed m».\ suggests how the projections can best be 
understood and used. 

Rimoses of Pppiecttons 

Eooncnic Mstory anply demonstnt^ the rise and fall of industries 
and of oocqpations. Fluctuations in supply is most liJcely in ooo^xitions 
requiring long txzdning periods, since it may ta)ce yeare for st^piy 
r^ponding to rvket siq^ials to get throug(h the oduoational pipeline. 
ytorkBors investing time and money in education, euployere conoemad about 
the availability of skilled warkere, and a public interested in stability 
of i«ges and prices and in getting services iiten they are needed all have 
an interest in our ability to antic^te changes in cnployment at least a 
fed^ yeare in the future. 

Rnpjectiora may be made for a variety of purposes, among wiich are 
the following: 

o Evaluating the adequacy of tndnix^ or education progr ams in 
the li^ of potential need for vorkere. 

o Estimating the feasibility of major proposed pr o grams for 
gcvernoent esqpenditure (such as defense, public varies, or facilities) 
in terms of the availability of skilled voflrioere to 
aoooqplidi or staf then. 

o Kx^iding information on future enployment opportunities for 
the guidance of individuals choosing courses of education or 

Exanples of the first of these include the insistence of the Congress 
that federally supported piujiams of vocational education and for training 
of the vnaBflaymA or ttie disadvantaged be plamed with future cnployment 
opportunities in mind. Similarly, the Oongreasdonal ooraideration of 
piujiaiim such as higiiuey construction, ccnmxnity mental health facilities, 
and the Special D^enae initiative (**Star Mhre**) piogtains — to name a fev 
— included inquiring about the availability of the hi^y Skilled 
personnel required. TSm Bureau of labor Statistics laurviied its 
occqpetionaTi outlodc research program in 1940 in response to the guidance 


- 2 - 

profession's oonoatn that your peopls have adequate infonBaticn by %ihich 
to chcxase among careers: the asm notlvation is b^iiid the efforts of 
state govecnnents to prcKdde Iccal projectiora of cnploynent growth ly 

Ihe raticnale and assunptions underlying the proj ec t ion wf differ 
depending en tteir purposes. BoUi vocational guidancse and evaluating the 
adequacy of training pitfjiaua to aaet future needs for alkilled WDrioers 
call for a realistic astLnate of Azture eooncnic denard in the 
occvpa t io n . Estinating the BBrfXMer faasibility of proposed progranB, on 
the other hand, calls for the tranBlatlon of the program goals whether 
or not they are realistic — into personnel, and adding to these 
requivanents a realistic estimate of the denand for the same types of 
workers in the zest of the eocnoB^. 

On the mjpsly side, for vocational guidanoe purposes projections of 
the most proiaable supply in caiparison with the eooncoic desand give the 
best picture of future eg{)loyment opportunities and tiie ccnpetitive 
situation in each field. For evaluating the feasibility of a prcposed 
program a forecast of the most probable supply is also desirable; It vaaLd 
show whether the piuyiam can be aaocq;>li8hBd tdthout ^lecial measures to 
attract more wooiOBrB to the field. For appraisals of the adequacy of 
present training prograias, on the other hand, a major element of the 
estimate of fixture supply — the nuEDber of trainees — is ttMb quantity for 
which the e a ce r cise is undertaken, the "X" in the equation, and there is no 
need to estimate it independenay. Gne way to look at the m^sfHy, an 
approach particularly useful evaluating whether the nmter of training 
slots is adequate to meet the demand, is to treat t:^ losses to the 
ooncation resulting fixm death, retitcnents, and net mobility to other 
ooc^pationB as conponents of "replaoenent needs", to be added to the 
estimated growth of the ooaqpation to get the total denand that has to be 
satisfied by the flow of trainees. 

In all the above %« have dlenwnwl Bcpply and demand as if they were 
independent of each other, when in fact they are interdepoident. An 
increase in denand, by raising wage rates, elicits an incxease in simply; 
and sipply alsc^ affects demand through its effects on wages and costs. 
Cnly when there are const ^ints on deoand such as those ispoeed by the 
technology of an industry (a steel mill can't cnploy pastry cooks to roll 
steel) , or oonstraints on supply, such as li'jtited educational facilities 
or licensure, is the wl^ustncnt of denand and supply iapeded. 

m those ooctpatiois requiring long periods of •Sucation or training, 
however, it may take several yean for the signal of an increase in danand 
to fill the educational pj^ine and produoe an incxease in graduates; it 
is for these ooapations that projections are particularly ineful in 
facilitating adjustment of demand and sifiay. In the absence of 
projections young people have only tlie current market situation to guide 


then, if they raact strongly to a cuxzent Bhoctage of graduates and high 
salary offers they findl that vhen they graduate, four years later, the 
field is ovezcrcMded, and salariw drcp, causing the current year's 
entrants to avoid the field and precipitating a chortage four years 
later. (Ihe operaticn of "cobweb" patterns in tte labor markets for 
hic(hly trained vcaMairB is dancnstrated in a naber of peqpers by Richard 
Reenan. ) 

PrniitrtlTTi Hp*frn1° 

A variety of oettods for projecting denand and simply have been 

Ihe sioplcet has been to ask enplcyezs hov nny workers they eoqpect 
to cnplcy in the future, ihis aathod appeals to oany people as 
strai^lhtf arward and a vey of taping tte eoqpert knowledge of the people «ho 
will nake the decisions. Yet it has ptoduoed such poor results that, 
after years of use, it was abandoned early in the 1970's. It was found 
that Uu cnployezs make the projections of their sales and techndogiced 
changes in their industries that would be required to develop good 
estiaates t.' their future ocoqpational requirenents; nost don't reply to 
the surveys or give casual, off<the-cuff answers. Ihere is seme tendency 
for each firm to assume it will gain a larger Baiioet share; and an 
offsetting tendency for orinvinleB to report that their personnel 
zequiremoits fiw years ahead will be the eane as now. Finally, this 
Method makes no allowance for cnployment in new firms. Which, according to 
some research, are a major provider of additional enployment. 

A second method that has been used is to eoctr^polate the past 
cnplc^nent trend in the ocoqpation. Ohis is justified cn the basis that 
whatever factors have operated in the past will continue. Uhfortunately, 
histocy is full of instances «hen the situation changed, as any buggy whip 
aanufacturer will attest. Another deficiency of this method is its 
treating the occupation as if it were in a vacuum, unrelated to other 
etvents in the eooncniy and in society. This is illustrated by the attaipt 
in the early l!;50's to aoctrapolate the growth of the eng i neer i ng 
pcof eesion by assuming that the eoqponential growth it had ihown \Kuld 
continue; in a short time the engineers would have fOfneedBfi the total 
labor force, leaving no draftanen to make the engineers' drawings, no 
bookkeepers to jpay their salaries, and no trash oollectars to haul aAiay 
their beer cans. 

A more scphisticated e^pproach has been to associate the growtl^ of an 
ooctqpaticn with causative variables that can thenselves be projected 
Independently. Piipjections of the population by age have been used, for 
CMoqple, to project the denand for teachers; the pipils in elonentary 
grades six years hence have already been bom, as have hicfh schorl 
Bttttents fourteen years hence. Changes in pi^il-^teacher ratios or other 
strategic variables can be used to modify the results of theee 
projections. Similar methods have been used to project the denmnd for 
ph/siciara (OlENAC) and nurses (NICHE) . In some cases regresRion analysis 
has bean used to measure the relative effects of the variables on the 
result — the projection of vploymBnt. 

- 4 • 

Ihis uthod nay be UMd to yield eBt±Date8 of the need for %porioers in 
the oocxpatioi, rather than the eocnondc demand. If the relevant ratios 
(euch as the pqpil-teacher ratio in the pr o jec t ion of iHi()loymBnt for 
teachers) are set at an ideal level in lira with %tet eoqperts in the field 
consider qptiaum, the reeultant projections can be viewed as projections 
of naec:. To the extant that tiMy are baeed on curmt ratios vhich in 
turn reflect the oumnt narket situation, or if they are adjusted for the 
fiiture to reflect expected changpas in the aaricet situation, the resultant 
estimate vill be cloeer to an estinate of donand. Each approach serves a 
different purpose. 

Ohe advantages of this approach CNmr thm siaple extrapolation of past 
trends are obvious. It attespts to take into auouurit mam of the 
strategic factorB affecting eq^loynent. It is not easy to take into 
account all the relevant factors, however; denand in an ocoi^ticn nay be 
affected by technological changee, aaxket changjes, the vay CQnsiDoers spend 
their Boney and the anount of inoone Idiey have to spend, gc^wnnent 
expenditures en education, health, hi^Meys, and nilitary aaterial, and 
the capital esqpendituies of industry. More than this, the context of the 
grovth of related oocupatlons and industries, and the entire intervoven 
stnicture of the econany and of eociety. Mien ann thihks about the 
factoTB affecting aqploynent in health ocapation, for exaiqple, the 
iiqpcrtance of population trends, social trends, incGoe and eoqpenditure 
patterns, the ecienoe and technology of medical practice, the financing of 
Aedioal care, training and licensure, and the growth and attractiveness of 
alternative oociqpations all oonbira to nake it apparent that a 
coq;xrehensive approach is called for. 

The Bureau of labor Statistics, vhich began its research in this area 
in 1940 and issued its first occupational projection five years later, at 
first tried the approach of studying individual occupations, but concluded 
that a conprehensive analysis vas needed. With m^ppooA tm the Veterans' 
Administration vhich vented inf ormaticn to help in the vocational choices 
of the ridJlions %*k) studied under the World War I G.I. Bill, BL5 published 
outlook infonnaticn on hundreds of ocoqpations beginning with the first 
Ooctpationsl Outlook Handbock in 1949. Zhe Handbook has be^ a biennial 
publication since the aid-fifties. 

The broad occupaticnal coverage, ft ^ equ e nt publication, and vide use 
of the projecticns (150,000 copies of each edition of the Handbook are 
bou^ by hi^ schools, colleges, libraries end comunity agencies) have 
had important iaplication for the research program, ^xreading research 
costs over so nany occqpations has nade pouible a won conprehensive 
BpproBA than could be supported if the interest vers only in a f ev 
occupatione. n^e contixaiing imifiFiiiJi effort has led to aocmulating 
experience, d ee pe ning kncvledge of each ocoipation, end ongoing contacts 
with industry, professional organizations, unions and lesnmi h institute 
familiar %iith each field. It has also made poeeible regular appraisals of 
the accuracy of the projections and analysee of reesons for errors. As a 
result of ttdm eaqp er lence nav reeeaiUi tituyiams and data collection 
systons have been instituted; exanples are the ftonrfttional enplo^PHnt 
statistics program begun in the early 1970's, and research on tables of 
wxLidng life and on how people aove trm one xd^tation to another to get 
insic^ on scne of the elcnants of sqpply. (Ver nearly five decades of 



- 5 - 

mpericnoe nathods havtt been changed and iixtxroved. The vide publlcaiticn 
of the results has assured that industry and professional groups in each 
ocxupaticxi have oooperated with the Bureau in giving inf annation and 
carefully zevdeidng drafts, use in schools and in vocational guidance 
undocMedly influences the perceptions of studmts about enployment 
opportunities and ttm ocapational choices th^ vake. 

Ihe basic approach followed is to estiioate the enployiDent in ea^ 
occupation that viU be generated by econondc denand, Ihis goes back to 
the dananl tor ttm goods or services the oocqpation provides, ml this in 
turn is affected by the total apendable inccstt available to oonsuners and 
govemnsnts and to the changing patterns of vhat they epend it on. These 
are influenoed by a vide variety of social and eoononic factars, incltxling 
changing tastes and styles, scimtific disccMarles and technological 
change affecting both vhat is produced and hov it is produced, the growth 
anl changing conposition of the population, taxation and gcvemnent 
eo^enditures ("^juns or butter**) , and %hat other countries are 

buying ftoa and selling to us. 

Ihis is a tall order, and guessing %hat vill hqppen in the future on 
so nany different fkonts is hazardous. Natural disasters, social 
catadysnB and business ^cles are hard to predict. But some of the 
changing factors nove relatively slowly: there are lags between 
scientific discovery and mnnflmlal e)qploitation of the new technology, 
betwem initiation of a nsv style and its videepread adoption, betvaai 
the first J^ianese autcmbile sold in the united States and the subsequent 
narket suooess. Ihis vum that if projections are confined to a 
relatively tf»rt tisie horizon (about tm years is enaug|h to 9iide 
educational policy and the career choices of individuals) , if sets of 
alternative projections are nade to show the effect, for exanple, of 
alteniative assunptions as to the state of the eoonony or the business 
^cle, if events are constantly nonitored, if the projections are revised 
at frequent intervals, and if continuous research is carried out on the 
accuracy of the projections and on the adequacy of the methods, there vill 
be a good chance that useful projections can be produced. 

Ihe Bureau of Labor Statistics projections start %iith the population 
projection sade by Census Bureau danographers. Ihis gives the ninbers of 
oamxmrB and serves as a ba^Is for ^projections of the labor force by BLS 
en Che basis of the trends in labor fierce pa r ticipation by each age, sex, 
and race group. Frm the total huonan resources thos projected, EES 
estiinates the gross national product that vill be generated, by oaking 
asswptiom as to the growth of output per vorkers, changing hours of 
voric, ard the level ot uneDployment that has to be allowed for. To 
provide for the uncertainties of the business cycle and to suggest the 
range of error to users of the projections, three sets of projections are 
tmally nade, depicting a fhig^**, a *tederate*<, and a *<low^ forecast; the 
asAzqptioni as to productivity, hours and unenployDent are adjusted to 
yield an estiaate of GNP growth under theee ttacm conditions. 

Ffcon the above bare recital of an elaborate prooees one nay get the 
iqpressicn of a aechanical juggernaut grinding roug^hshod over the entire 
eoonony of 110 million people, in all its ooqplexity, nuances, and 
Infinite variety, and nshing up the professions ve are interested in vith 

ERiC ' ^"^0 

- 6 - 

aasaas of ooal miimru, ftactory %«ioBn and fast food slingexB. ttiat has 
not bMn said la that at aach atoi? MpKihl knwladge is ixitroduoad 
ilMnavar it is availitbla, aid tha fiictocs antaringr into tha calculaticra 
are adjiiated en tha hmim of inftaCBaticn on davalcping and navly cDerging 
trends in tha industry. Zh nost rioant projacticns, ftar maanfle, 
pgojections tor the lining inlustrias tales into aoocunt tha latast 
petrolaiiii iiinrt analysaa for the target year fkon the Dqpertnent of 
Ehergy. Rxajactions for tha sachinary and ODBpntar sanufacturing 
industries in o o c por a ta analyeas of thi anrioet situation and foreign 
ocnpetition* ftojaotiona for health servloec nmslrter such dsvelqpnents 
as oost oontaimsnt policies, aid ihift of aany surgioal procedures to 
dxtors' officss and outpatimt fivdlities, growth of nefar group practices 
and nursing and personal care facilities, and the egixig of the 
population. The Bureau's exten^ve reeeeiiA pr ogr am en productivity and 
technological developMnt yields insi^^hts as to tho gronth of overall 
productivity, of productivity in each industry, ard ttm technological 
dsvelopBants affecting tiM nuBobers and kinds of ocoupaticne enplGyed. The 
advantage of the ooqprehensive interactive approach is that special 
inf onnation or analyses on any aqpect of the oonplex eoonony can be 
inserted and the inplications, not only for a peo^ioular occupation on 
industry but for all others, can be drawn. 

on the MppLy aide, in contrast, there is no unifying and systenatic 
nethod for p r oj ec t ions. The supply of vorkers in an ocoqpation if 
affected by the inflow of trainees unA of persons %to acqjoira the 
necessary skills by experienoe or work in related ooapations or by stud^ 
of related subjects, end the outflow of persons retiring, dropping out of 
the labor force taBqporarlly, dying, or transferring to other oocupetions. 
The sifply is, of oouree, affected by relative vages in this and other 
occqpations available to ttie vorkers. 

Rnpjections of the nnber of collegre graduates in each field have 
been published by the Dqpartsnent of Bduoatlcn; tb^se vera based on the 
projected population of the appropriate age and aathenatiail extrapolatior. 
of trends in the proportion of the population oonpleting college. The 
total degrees %iere distributed by field (college majors} by nthenatical 
extrapolation of past trends. Slnoe there was no atteBpt to take into 
account the effects of social and narket factors on the decisions of young 
people (except insofar as these factors vera esobodied in the past trends 
projected} ^»y caraiot be oonsidered realistic. The/ do, however, serve a 
useful purpose: they can be used to illiistrate %tet vould happen to the 
outflow of graduates, on ia{»rtant oaipci i e i iL of the sqpply, if nothing 
happened to change tha choices people sake. If such estintes are 
ooni)ared to independent estiaates of Mxm dnand or the reciairemmts for 
attaining seme national goal such as a pcqpoeed consunit/ aental health 
program, a disparity between the projected doaand and the prtyjecterl Mpply 
could point to policy neasures required to attain the goals, such as 
scholarships or other induoosents to take trailing for the oooupatiora. 


- 7 - 

To get a handltt on the cutflawB and inflows affecting oocupaticnal 
Kfply, the ELS has pursued a nuD^Mr of avenuas of xssearch. To estiaate 
losses resulting fkcn aaaths and vstijwants, tades of %xirking life 
(sinilar to life tidaies) were developed, shewing the annual attrition to a 
population at each age. these ag e ijwif ic rates were an)lied to the age 
ooqposition of each oocMpation to estinate arvual losses. These, however, 
take no aoooont of diffennoes in wock life patterns aBBong oooqpations, 
nor of losses resulting fton transfers to other oootc^Btions. Hore 
reoantly studies have hem aede of transfere into and out of nocqpations 
(Ecdc, 1984) and Bore oaplete attrition rates for each oocqphti on have 
been estiaoted, including lAiifts into unsofilcyBsnt and withdrawBl fron the 
labor foroe (either rstirenent or taninrary withdraual) . 

Ihe BL6 does not oake prpjections of supply in ooci:qpations. It does 
publiiA) estimates of ainial attrition or replaoanent rates. Ihis 
infocnotion is offered, together with tin pcpjacted rate ot graw^ in each 
ooaqpation and infonnation on the unoq^loynant rate, as clues to the 
aq^ayment opportunities in the oooupation. Ihe inclusion of infoonation 
on replaoanant rates nates clear the point that projected growth alone 
does not tell the whole story about anployment opportunities. 

ftpjecticns of eq>lcyment denand for aoce than 300 oocupations are 
publidwd in technical articles and bulletins. (The nost reoent 
projections of general eoonondc growth, industrial growth and oocupations 
were published in the Monthly Labor Review for Septenber 1987) . Brief 
articles on each of about 200 oocqpations involving relatively long 
periods of training are publidwd in the Oocupational Outlook Handbook, 
and profiles of the basic nunbers — enploynent, projected csployment 
growth, unenploynent rates, replacement rates, and nunbers ocnpleting 
training in a reoent year — for itoit the same nunber of ocaqpations are 
published in a series of bulletins called Ooopaticnal E^pjections and 
Olndning Data, of «hich the most reoent issue was in 1984 (BIS Bulletin 

State and Tnoni Pmiflctions 

m nest states projectionB for the state and major geogngphic areas 
within the r^ate are made by state agencies, most ocrancnly anployment 
security ^ancies, but scmetimes universities or other eooncnic analysis 
organizT'^xons. Until a few years ago thve was a cooperative 
federal-ctate relatioraAi^ in this wark, vLtti ths Bureau of labor 
Statistics providing technical consulting and smwMmm tidaulation %park, 
but this was dropped as a result of budget outs. The states continue to 
work, however. Ohe National Ooaqpation *. Ihfomation Ooardinating 
OGnmittee, mirfml of representatives oi. the OBpartmen^ of labor and 
Education, and its affiliated state occupational information coordinating 
oonmittees give leaderdiip to thees efforts. 



- 8 - 

Uta BBthods thsy foUov diff«r, bit have a fw •lounts in oomcn. 
Ihe naticaial pixjjactlGnB of growth of Industries atB generally taken as a 
fitamswQiic, snd the past ctenges in aach state's share of natlcnal 
cBployment in the industry, together with parojectlcra of the statue's 
pq;ulaticn, and irpit fran tiie eocnonic developnent agk'cy of the 
ntate are ueed to project the industry's growth locally. Lidustry 
cno^ational c ynro si t icn data fccn the Ooaqpaticnal BiplcyBent Sur.^ 
(which is conducted by the state agencies in oocperaticn with BLS) are 
use.i to porpject aplcynent fay o a c i. Tati on. R^Oaonent ratee provided by 
the BLS are also published. 

P/aluatitan of Wfy Pmi^ ietiona and > • 

An evi luation of the aathods ihu^t begin with a look at the 
'recard;'oir accurate the ijcojections have been. Ihe Bureau of Labor 
b^tatistics he publidied a niober of evaluaticra of the accuracy <~f its 
proje .cions, ocB^aring than to the actual enployBent in each indubt .y and 
oocipaticn «hen the target year's statistics became available, ffe will 
refer to the two nost recent evaluations, those for the 1960-1975 
ppjections (Carey, 1980) and the 1970-198r prpjectiora (Carey and 
Kasunic, 1982) . (No more reoent evaluatioc^^ have been published, in part 
because changes in the cOassifir^tion systan for ocoqpatiora have it 
diffiojlt to occpare earlier pn: ^actions with current eBployPTnt data 
since 1983.) 

Oonparlng a prpjecticn that purports to reflect daiend, without 
regard to si^ly, with the actual enplcyment in the target yeir is not 
entirely logical. It is justified only if one can assum that the sisply 
will oome forward to natch the demand, «hich does not always h^pen. 

Ohere are a lusber of %nys to look at the accuracy o* projections. G»e is 
to oonpare the nunber of «naioBrB cnplcyed in the target year with the 
naber projected. Ihe purpoee of the projections, however, is to 
anticipate change, to distinguish ocnqpations growing n«>idly and slciflv, 
and eqpecially to do the mre difficult tr-sk of identifying ocxxtations' 
that shrink while the eoonony as a KhoJe is growing. Our evaluation will 
therefore oonoentrate cn how well the ir.ite and dir^Aien of f^rr^ in 
enpioynent %ns projected. 

Tbbegin with one ihould look at the degree of variabilty in growth 
rates among ooaqpaticns, to see vhat the forecaster is up agaiist. Xf 
grcuth rates vary in a narxow range around the average we should eomect 
projections to ocne close; if they are widely dispersed, the prpjecticns 
nay be judged by more lenient standards. Ohe foUowing tab3^ arrays the 
actual changes in cnploynent in oocqpations iiKduded in the two BLS 
valuatior. stiidies referred to according to broad groipings of their rates 
and directions of change as oonpared to the average change ftar all 



- 9 - 

Growth Rates in Bqplcynent in Ooaqpations 

19S0~1975 lg7g-1985 

Average (waightad) change for all 
cxaofiatiara 32.6% 28.9% 

Total luriaar of ooofaticrs 

76 64 

Oocvpetions with: 
Dacainas in wnfUagtBorA. 16 20 

Incxaases in aqplcynant 60 44 

Below average (sBce than 10 
pexoentage points belcw 

the avwrage) 11 10 

Jkbcut ave^^age (within IJ 
peroent&» , poin^3 above 

or below the average) 17 9 

Sanswhat above tita average 
(between 10 peroantage points 
above the average and twice 

the overage) 11 U 

■IVioe to triple the average 11 5 

More than triple the average 10 9 


- 10 - 

Htds little table oould veil have been nade the pref aoe of this 
paper: it powe^'-^ally afiac r pL jates the variability of oooiyaticnal change, 
the risk underUcm by anyone yto invests in long and expensive training 
iTor an ooopaticxi, and the difficulties the forecaster is q> agaiiut. In 
a ten or fifteen year period \im\ the average oooupation grm by about 30 
percent, bebmen one-fifth and ore-third of the oooupations actually 
declines in enployment. Tha nunber of oacqpatiom that grw at a rate 
triple the average vas about the same as the nater that grw less than 
the average. Hwrm virtually no cluTtering around the overage. 
Obviously ooofxitiGns are hi^y volatile in their eBpLoyment and subject 
to diverse eoGnondc farces. 

An evaluaticn of hw veil the EES prcjecticns for these oootpaticns 
sucx^eeded in predicting the actual changes shown above (Goldstein, 1983) 
oonclxxied that, first, users of the projections hrd sens %iaming of the 
declines: five of the 16 that declined frcn 1960 to 1975 had been 
predicted to decline, and aoall increases of less than the atverage had 
been predicted for the other U. In the 1970-1980 period, six of the 20 
ooctqpaticns that declined had been p rojected to decline, and eanll 
increase of less than the average had been projected for seven nore. 

Seoond, did the p rojections identify the ocoupatione that vere 
growing vary rapidly and needed ^)ecial attention in planning training 
programs? m the first period, 21 occupations grew at more than twice the 
average rate; 15 of then had been projected to grw that fast, '^n the 
so oo n d period, 14 oooppations grev at more than lw5 the average rate, 
but only two of then ]md been projected to grow thaw fast. 

Taking all the projections, how close did they come to the actual 
employment changes? Going back to the class ititervals shown in the table 
above, ve may say that if the predicted changye vas in the same interval as 
the actual change it vas on target, ^txc the first period, 40 percent of 
the predictions %pere on target, for the seoond, 33 percent. If %#e 
consider th2kt if the prgcdctions %iere in the class intervals adjacent to 
the actual change they were reasonably close, we find that 40 percent of 
the predictions in the first period and 27 percent of those in the seoond 
period were reasonably close. Ey these standards, perhaps soneuhat 
lenient, but with leniency justified by the variability of eoaxnic 
enploynent changes, ve get 80 percent of the projections in the first 
period and 6i percent in the second period either on target or reasonably 

Mere the eircrs biased so that prpjectiaoe vere oonsisbently too hic^ 
or too low? Of all the projections in the first period that inere not on 
target one-'third were too low; in the eeoond period rcug|hly half. So 
there is sone evidence of a pessimistic bias in the first period. 

one question the KM ooenittee staff on this project needs to ask is, 
how well the method predicts thm growth of the ooaqpatione in adch it is 
interested, the allied health professions. It is a xeasondble hypothesis 
that the eoononic, technological, social and institutional factors 
peailiar to the health industry and its oocupatiora may medoe the genenl 
projection method used by the ELB inappropriate to this field. 

- 11 - 

Ohe «val\»ticn studies we have cited do not incluJe namy of the 
allied health profeesicns, largely because the/ indvried cnly oocupaticns 
for «liich the statistics vere ocnparable over the ten or fifteen year 
agem between the original pcpjections and the the taxget years; for 
allied health pvcxfassions, with their dynamic changes over reoent decades, 
the data needed for ocqparison are not available. But we can test the 
l^pcthesis of peoulierity with evaluations of the aocura:^ of the 
j^ections for other health oocupaticns. 

Ihs ftillowing table shows the projected and actual flq;>loyDert changes 
in peroents frcn 1960 to 1975 for six health oo c up at i cn s; 

Prplected Actaal 

nurses, professional 73.5 6&.5 

Dieticiam and nxtritinoists 35.1 44.6 

Cptonetrists 17.6 10.0 

Attendants, hoqjtial and other 140.7 122.4 

Dentists 43.8 23.1 

Riysicians, nadical and osteopathic 66.7 40.2 

For the 1970 to 1980 period we have: 

cptonetrists 20.0 19.4 

Osteopaths 43.7 39.3 

FliyBicians and surgeons 43.5 43.3 

RagistSTR]! lUTBes 42.7 59.9 

Dentists 32.0 22.3 

It qppears ttiat the projections captured ttm gmeral aagnitude of the 
enploynent ctianges in these fields rather better than tiiey did for all the 
ooacMtion enmluated above, althougfh one oould %iijh tec wan accurate 
pcojectiora fbr dvitists and pliysicians in the first period, and for 
mrses in the second. Ron this, the hypothesis of peculiarity of the 
hjBlth fields is not wqppcixtmSi. 


= 346 

- 12 - 

Let us turn to maae of tha aspects of the ptojactlcn lethod that 
xaise qnHitiono cr prsetint problons. 

In tzaditicnal frryanip analysis daaand and supply ax» sqoated av a 
Forics or tAge; but thexB is no saqplicit cvidmos of this in tha BIS 
pcojaction Mthods. Instead, ths •B|>lcyBBnt sstintas for ftiture ysars 
■ay be SMn as xaSBlixaDGDte gnaraitad ty ths levels of psoduction or 
servioes that the ptrpjectad eoononic ciiangps will give rise to. (indeed, 
c»ian9ing zelattive prioss ttomug^nxt tha syatsn oould change tha eocmdc 
ralationahlp pocDjactad, as for aKenple in tzadng ths dnanl tac raw 
■aterials ganerated by prodocticn of finiatoad goals. However, the 
adjustanents aada at various stops in ttm pKooass to introdboa 
tadmolcgioal change and changes in nrksts and foreign trade have the 
effect of inserting prioe and aarfcet changM into the systan.) 

Ac the end of the porooess there is indeed no systaatic attanpt to 
ioodify the aqploynent eettaates tat each oocqpation fcy ooraideraticn of 
sqpply. lacking projer^Jons of stqpply, this oamot be done. Ihe 
projections of ooacaticnal •■laayniaTt': %dll be consist jit with actual 
Mployment in the target year only if v'he sifply of traizwd wodparb 
(pezhaps ftorsuaxned by publication of the eetinatas or, in tha I960's 
refolding to policy eeasures designed to raise sqpply to aaet incxeased 
demand rr ^ting from nsv entitlcnent programs) adjusts to the enplcyer's 
regiiirGnKuits. Miile not true esUnates of dvand in the aerae of 
traditional e rm r mlc concsepts, the prpjectiora do, however, oqb» ^loee to 
the goal of a realistic estimate of tte nunber of jobs that vi e 
offered, as distinct, for exanple, frcn an estinate of ideal aa. 

r)mJr^tifw»^ orwj^^x^^ of Indushriea 

Ihe evaluations of the aoouracy of the projectiom aade by the BLS 
staff ooncloded that the industries' total cnployment was aoce accurately 
projected than was enploynant by ooopation. Ftm the fbregoing 
discussion ipb ni^ suspect that the lower accuracy of oocqpational 
projections aay have resulted from the fact that the dannd had not yet 
been oonfkaited vith the sqpply, and if it had, a rliffennt level of 
•qploMinent would have enezgad. 

lam: aoouracy oould also have resulted ffccn ttm quality of the 
oocavational data; until reomtly the only reasoradbly oonplete souzoe of 
data on the oocxpational orwrnslttnn of each industzy was ttm decemial 
census of pc^fulation. In hou se h o l d surv^ such as f puses people rwort 
their ooofetion by whatever name thjy have to dwcribc " and tell the 
oanais mandator briefly what activities they perfcra. Ohise zworts are 
classified by census clerlcB into the 400 or so oocqpations the oenus 
tabulates, ihere 1« potential error fint in the respondent's zwport: 



- 13 - 

MM people uvorstate their ooaqpational status, u is evident frcin 
independent data. Sooond, the census clerics do not alvays have enough 
infamaticn to classify the ooctqpaticns oorrr^ly; terminology varies^ 
across ttm ooisitry« (Itae same CGonents aiply to another source of 
occupational maplagmrtt data, the COmnt Population Survey, ocnducted by 
the Census Bureau. Ohe VPS occqpaticnal estimates, based on a snaller 
sanple than those in the pqpulation cmsus have larger sanpling errars and 
scneuhat less ocoiqpBtiGnBl dttail is pMiii^ed, but they are available 

lt> inprove the accuracy of occqpational ocBpositior. data, the BEL5 
initiated an Oocqpational Etaployment Statistics survi^, in cooperation 
%dth state agencies early in the 1970's. Btploynent by occiq^tion is 
collected frtn enployers by seam of a separate questiomaize fbr each 
industry, listing the occupations found in that industry, with brief 
definitions that have been worked out in consultation with enployers, to 
assure understanding and ability to report accurately. Ihe sanple plants 
in the survey is chosen to represent all size clasnoff in the in \2stry and 
to yield accurate estinates. 

Ihe survey is limited to vage and salary vorlcBrs in each industry; 
the self-enployed are added in each occupation by BUS, using data fton the 
current Population Survey. 

Since it is based on reports from eeaployers, the OES counts each 
vorkers more than onoe Lf he or she has more than one job at a tiine. Ttdj^ 
ixitroduoes a aoall inaoouracy in the occupation enployment estimates; in 
the sories of surveys of dual job-holding that was made fkaa 1958 to 1980 
the nmber of persons with more than one job averaged about tim percent 
of the total eqplcyed — six percen t fro men and three p ercent for vcnen. 

The estimates count iiiorkers whether they vor): full-time or part-time, 
and do not distinguish. Ihis means that in any occupation there could be 
many part-^time %xarkers in the figures. In 1986, 18.7 percent of all 
persons at %park %iere working part-time — 5.3 percent fbr economic reasons* 
(no full-time vork available or they had been teDpararily on p'Tt-time) 
and 13.4 percent voluntarily because they preferred part-time vork. Ohere 
is more part-tine irork among vonen — 27.5 p e r cen t vers on part-time, 6.5 
percent for ecGnonic reasons and 2^.0 percent voluntarily. Ihe incidence 
of part-time vork varies among occupations: in the occupation gro^ 
"^technicians and related support perscmel** in %hich many allied health 
professions are included, 12.9 percent %iere part-time (2*2 percent 
economic) , and amc^rjf vonen technicians 20 pooent vere on part-time, 3.4 
percent ecmomic. (Data from the current Population Survey.) There are 
therefore fewer fUll-time eqidvalent jobs than the nuDber eqployed in an 
occupation iaplies; CB{>loyers and vorkers have adapted to this. 



The definitions of Mch oxupaticn warkBd out for the OES were, as 
noted above, designed in copperaticn %dth entdcyers to facilitate 
iepa(rting. ISwy have to be both understood within the culture of each 
industry and consistent across industries so that the «n|)loyinBnt estintes 
for each oocqpatlcn are additive. Ihis nay not always pirDvlde the nuances 
in definition that pcofessional socie t ies, ocroe i neJ about qualif ioatiora, 
licensure and sinilar BBtters, would liXe to have. A liat of the aliiad 

Ne have wgpgested tuo reasons for the lower degree of accuracy of the 
oocqpaticnal «q;>lcyBBnt projections ocniared with those for industry 
mfla^/amA — that the donand projectioni are not terted agaimt 
oofi fwt io n al mqpgHy, and that the basic data cn ooofational ocBfXJsitlon 
of industries used in the past pcpjrctions was inaccurate. Ne should 
consider a third reason: that th^ way in which occupational coicxsltion 
is changing is not i«ll tnderstood and the adjustaents inserted into the 
system to allcw for the effects of technological end other changes are not 

Ihe theory underlying the use of ooopatlonal oonpoeition data in 
forecasts is that the technology of each ixxSustry and the vay it does its 
business calls for a unique adx of occupations, m a gross seme this is 
certainly true: pastry cooks are not cn{>loyed in steel rolling mills. 
Bat t here could be dlf fozences among plwits in the sane industry resulting 
fren differences in process, in eqd^pnent, in the way the work is 
ocganlssed, in the local simply of trained woricers and the extent to which 
less-trained woiicezs are substituted for then. Ftsr those finnillar with 
hoepltals and other health service InstitutionB there is no need to 
belabor the point that occupational conixsltion nay differ fzon one to 
another for many reasons. 

itwn the acting coBsilssioner of tha Bureau of labor Statistics first 
testified before Gongrees on tiie request for finds to do occupational 
cutlook r es ear c h he said he would look at the occupational ccBpositlon of 
the technologicaUy most advanced plants in each indaetry to get dues as 
to the my cjuposition would be changing. How, nearly a half century 
later, this kind of analysis is made possible for the first time by the 
OES. Not only are the o m f nit io n statistics better, but the ooUectlon of 
reports fror individual plvits offers the potential, never before 
available rxoept trcn a few industry wage surveys, for analysis of why the 
omyat lon al oonposltion differs among plants in the sams inlustry, and 
hew it is affected by size of plant and new technology — analyses that 
may lead to hctter projectlcns of ooopational cnploymBnt. 

staffing of the Preleette ns HeaamA 

Uie BIS ooovational outlook reeoarcfri staff has been reduced over the 
past tm years as a result of budget cuts, and the burden cn individual 
staff merdaers therefore increased. With seme 200 ooaip»tiarm to cover 

- 15 - 

with articles in tha Ocxiqpaticnal Outlook Kanclbook, they are epcead thin. 
Itevarthelcss, «hen the Katicnal Acaden/ of Science ^taff visited then to 
discuss their pcojections, it was found that no fewer tiian four eooncnists 
wece working cn health oooiations. lhay %«re in touch with develofnents 
in their fields and in ^ health care industry generally, and familiar 
with issues and the findings of recent studies. 

Qnnriluaion; Ifea afThe Proiaetiens and IMrtfaer Beseardi Needs 

It should be atumwit that forecasting for years in advance is 
hazardous, and this aqpecially applies to eqplo^iBnt ky occqpaticn. While 
there is hqpe the data and nethods %dll iaixrove in tiw future, at best the 
(tograe of error will be reduced soneuhat. The user of poxijections has to 
]QBep this in Bind and to take then as only loug^ indications of the 
directJcn and gmeral nagnitude of changes. 

Of ^Hm prpjecticn nethods we have reviewed, ^t of the Bureau of 
labor Statistics ai^pears to be the best in its abili^ to take into 
account a uilt^ici^'' of factors. Th^ have been at it Icng and 
ocntlniously; they have r^rmmt^mt^aA esqperienoe, knowledge and contacts in 
each field; they check their •rrors and are innovative in iqprcving data 
and Methods. 

Iter looking ahead in the allied health profession the Itetitute of 
Hedicim connittee would be %«ell advised to build on the %PQrk BUS har> done 
— not necessarily to accept the projections without question, but to take 
advantage of the analysis of the ficanewock of the U.S. eoonuiy within 
«hich the health industry operates, and to exBrnlne the assunptions and 
judgments va3i by BL6 staff in the health fields and, if necessary, nodify 
the results for NAS use. Our discussions with the BIS staff nade it clear 
that they are samestly searching for understanding and %K3uld weloone any 
irai^fhts that would inprove their projections. 

Before we can have any assurance that the siqpply can be understood or 
pttyjected nore reeearch need to be done on occupational nobllily and the 
factors detcundnlng how people lAiift among ocoqpations. Ihe sane nay be 
said abextt the factors affecting occupational choice. 

on ths donand side, the weakest link has been in converting 
prpjections (tf cqploynent ky industry, which had a fair degree of 
accuracy, into projections ky oocqpation. Analysis of the factors 
affecting the occupational conposition patterns of industries can now be 
done sinoe for the first tine we have ooofxitional data for individual 

Ohe practice of the BIS in publishing its pcpjections has been to 
issue only 10-year or latpv projections, without ttm intemadiate years, 
yet the latter era likely' to be ncre accurate, sinoe they are doaer to 

we ncr- Imow, and they are useful for nary p ur pose e . Ihey also lend 
thennelves to nore fkequent evaJ.uation of accuracy, which wxdd enable the 
BLS to o utiec t the nore distanc projections. 

Er|c 350 


- 16 - 


any, Max L. 1980. "Evaluating ttm 1975 nqj«c±lcra of Oaa^ational 
BtdLcyMnt". Monthly labor Rtviw, 103 (JVme) : 10-20. 

Geuney, Max L. and Itasunic, Kevin. 1982. "Evaluating the 1980 ftpjactions 
of Ocsqpaticpial EB|d.cynBnt". Monthly labor Raviaw, 105 (July) :22-30. 

E^, Alan. 1984. '^iotf Oonciational Siparatlon Data iBixcova BBtinatas of 
Job aylanwimnt Maeds" Monthly labor Raviaw, 107 (March} :3-10. 

Goldstain, Raxold, "Iha Aoouiacy and Utilization of Ooofational 

Ibraoasting" in Mbart B. Taylor, Hcuaxd Roan rnd Fkank C. Ftatzner, 
ads. BniwlYr^ of Tralnlm Ihgtltiitiona to Qiancrim Twhnr Martet 
SSSBBEOOm. Oo1u±U8, Ohio: The national Qaniigr for Reaaarch in 

Ynmtlmnl TH^otien- i983. 



JHFpendix VI 


Minnesota Statute 214 (enacted 1976), Section 214.001. 

g\iMlYlffi^ll 1i ^ legislature finds that the interests of the 
peqple of the state ate served lay the regulation of certain ooofjations. 
Ohe legislature further finds: (1) that it is desirable for boards 
f^rm^^^^tu^A priaariiy of Badaers of the ooocciations so regulated to be 
charged vith fomulating the policies and standards governing the 
occupation; (2) that eoononical and efficient aikiinijitration of the 
regulation activities can be achieved throu;^ the provision of adminis- 
trative services by departaentP of state govemnent; and (3) that 
procedural fairness in the disciplining of persons regulated by the boardi^ 
raiiaires a separation of the investigative and prosecutorial functions 
front the beard's judicial rasqponsibility. 

fiii^^viB<on 2. Critfiria for regulation. Die legislature declares 
that no regulation shall be inposed upon any occqpation unless required 
for the safety and well being aC the citizera of the state. In evaluating 
whether an occupation shall be regulated, the following factors shall be 

(a) Ihether the unregulated practice of an occiqpation nay ham or 
endanger the health, safety and welfare of citizens at the state and 
whether the potential for ham is recognizable and not rsBcte; 

(b) Khether the practice of an ocopation requires specialized skill 
or training and whether tiie public needs and will benefit by assuranoes of 
initial and continuing occupational cdoility; 

(c) Mtether the citizens of this state are or any be effectively 
protected by other means; 

(d) Miether the overall cost effectiveness and eoononic inpact 
be positive for citizens of the state. 

stlbdivislon 3 . If the legislature finds after evaluation of the 
factors identified in subdivision 2 that it is necessary to regulate an 
ocoqpetion not heretofore cxedentialed or regulated, then regulation 
should be ixplenented consistent with the policy of this section, in nodes 
in the fbllowing order: 

(a) creation or extension of ocnnai lav or statutory causes of civil 
action, and the creation or extension of criininal prohibitions; 

(b) Xnposition of inspection requiments and ^ ability to enforoe 
violations by injunctive relief in the caaldi 


(c) nplMitation of a systcn of ngiitretlon itenisy pcactitionexs 
vho vUl b« th» only ptnoiw pemittad to use a designatad title aza 
listed on an official roster after having aet pradetemlmd qoalif icaticra 
[note that legislativa action is not ragoirad taera]; or 

(d) fiqplaamtation of a lyBtaB of lioming iteifcy a pEactitioner 
aust raoeiva raoognition by the state that ha has aat pradetenninad 
qtialificationa, and peraons not ao lioansed ava pcohihitad fEon 

Mimesota Rules 4695.0600 vactoEs for OetenDlning the Naoessity of 

fiiihTwrt 1 ■ Qnnai<Wr»tim of faetara. Xh the review of an applicant 
grcup qjestionnalra, ttw sufcconnittee, oDuncil, and oamissioier riiall 
base their raoonaMndation or declaion as to whether or not the «qpplicant 
gnxp ahall be ragulated vpan the factora contained in MlnMsota Statutes, 
eectlon 214.001, si^visicn 2. 

fiiihnwTt ?■ Factor of imrBaulatfld praehioa. m applyixig the factor 
of vhether the unregulated practice of an ocofsation nay hazn or endanger 
the health, safety, and iMlfara of citizena of the state and whether the 
potential fior hazib is recognizable and not ranota, at ainiaun the 
xelevanoe of the foUouing tfiall be oomideEad: 

A. hazn diall be oonstnied to be condition npcesentative of 
Fhysical, «notional, aental, aocial, financial, or intellectual i]i|)aizBent 
zasulting frcn the functions rendered or failed to be l an dei e J by the 
applicant group; 

B. potential for hazn nay be recognizable «han evidanoed by at 
least one or nore of the foUowing: wpert testianry; cliait, oorauner, 
or patient testinony; i^ifui:h findinga; legal precedents, financial 
awBzds, or judicial rulings; 

C. potential for hazn nay be recognizable when evidenoe by at 
least one or nore of the follawing chazactaristios of the i^^Iicant gtxxpt 

(1) iiiwzantly dangerous nature of the i^iOioant gzaf>'s 


(2) dangerous nature of devioas or substances uaed in 
perfaoaing appllaant groqp's fimctima; 

(3) eaearciae fcy practitionera of the applloant geoupB of an 
observable dagzae of independent jud^nent iten: identifying or evaluating 
a oonaaner'a or client's iv>ptons; fanailating a plan fbr ooratnar or 
client care, service delivazy or tzeatnent; antVor providing ooivunar or 
client care, delivering aarvice, or inplanenting a plan of tz^itwatt; 


D. potentdal fca hazn oay be nmote when evidenoed fay at least 
one cr nare of the foUcRdng: infteqiMnt or rare instanoes of iiqpaizsient; 
iB^jalxnent %iiich is aiinr in nature; cr aecxndazy cr tertiary effects of 
the applicant grcup's function. 

fflltirmTt (?CT^TffltlTr BTPrinl Aill factor. In af^ying 

^ factor of whether the practice of an occupation raqaizee qpecialized 
fljdU or training and whether the pid^lic needs and %dll benefit fay 
assurances of initial and oontinoing oocqpational ability^ the odstenoe 
of the foUowinsr itm ihall be oonsiderad as indicating that apecialized 
•kill or training or their continuation is raqciired: 

A. that function perfo nued lay the pcactitioner are eeveral 
and tiieir perfarmnoe necessitates a thorough understanding of the ocnplb. 
relationship between those functions; 

B. ^t the one or nore functions p e rfooned fay the practitioner 
xeguizes a detailed understanding of the qpecif ic ocnponents of the 
function and the relatiorahip between the functions and the synptonB, 
problem, or ccraidion that function is intended to address or ameliorate * 

C. that the daeence of specialized ridll or training is liJcely 
to ixKxease the incidence and^or degree of ham as defined in nifcpart 2 to 
the consumer as client; and 

D. ^t there o oca r frequent or major changes in areas of 
aldlled knowledge and technique of which the practiticner mist keep 
infcoBBd in order to neet current standards. 

f^^r^ A. Tac±ar of mare «ff«*ivB weans. Hi applying the factor 
of whether the citizens of this state may be effectively protected fay 
other Bears, at a Bdniaum the relevance of the fbllcwing shall be 

A. miicators of protection fay other naans ehall include tut xic 
be limited to: 

(1) sqpervisicn fay practitionars in a regulated occxpaticn; 

(2) eodsterioe of laws governing devices and substances used 
in the ooo^tion; 

(3) eodstenoe of laws governing the standard of practice; 

(4) aodstence of standards for pr^essional performance 

(5) eeploysent in licensed tumn service facilities lAiich 
are required to tnploy ocaqpetent staff; 



(6) flodstanos ol ftdsnO. lloenBijig as cxBdoitialing 

<7) «dst«n» of dvil Mivloa pcootAstm «hlch •ffacbively 
potential maglagtm floor oonpatnae; 

(8) gnduBticn of Moban of tfaa anaioant giaf> frcn an 
acxzadltad aducaticnal Imtltutlon or training 

(9) nndatoty particiintion in on-tiia^ob training 
Which axa raqioizad by law cor lay professional csganizaticn of the 

(10) aodstanoa of professional cxadntials and staidards of 
parfarsanoe which effaotivsly sancticn nelpcactioa; anl 

(11) eodstanoa of a national oertification process which 
•ffectively attests to tfaa ocBpetency of recognized professicnals. 

B. Indicatocs of protection fay other aeam rtiall be ninnnefil and 
cwaluatad at least in view of the sxtmit to which they: 

(1) address all practitionars witliin an occupational gxtup; 

(2) appear sufficient to protect the general public frcn 
ham caused by the practice of the ooopation in questicn; 

(3) appear to be peraanent and ongoing nechanius. 

^ Subpart 5. Qmii cost sffaetivmeM mta ^nritrrlTT liimd- m 

dstentdning whether the ovarall cost af fectiveness and soancntic Imact 
would be positive for citizens of the stata, the foUowing shall be 

A. Bositiva cost affactiveness and •'^'■■^i*^ iapact results whare 
the benefits eoqpecbed to aocxue to the public frcn a decision to i«gulata 
an ocoqpation are graatar than tfaa costs resulting fton that dscision. 

(1) Cost affactivaness naans the ralatiorahip of the 
benefits anticipated ffeon a decision to regiOata an ooopaticn to the 
ovarall costs to the public resulting fkon that decision. 

(2) Booncnic impact naans the direct and indizact affects on 
the price and n^ply of aarviaas propvided by the ooovetion under 
oansidaration for rac^ilation. Ddract affects incl\ide inacts on the cost 
and sii^ly of practitionars who would bs regulated. IMinet affect 
include: the degree to which the eodsting practitionars will ba precluded 
trm practice because of regulation; the dagrea to iliich parscm aniring 
to practice the occupation, if not for regulation could pcactioa the 

oooqpatlon ucxBSsfully, but will be ponohibitad booKOBB of inability to 
BMt entry nqfuirenents; iqpack can ability of ainoritina or pre" acted 
claaees to enter oooqpetiGn; or iapsnA on innovatione in the delivery of 
oare or eervioee as a re su lt of regulation* 

(3) Oosts of a decisicn to regulate include the estimted 
oosts to state and local goK/exmnts of administering the proposed 
regulatory program; ed^tioml reqoiments and training oosts inclvxlinr 
oosts associated with escperiential reijLiirBMnts of the proposed sole ^f 
regulation; and oosts to the pidlic such as redkxaed or increased aooess b/ 
potential or existing providers to labor aarlcets. 

(4) Binafits of a decisicx) to regulate an oocupation Inducia 
aooess to less edqpensive but similar providers; aeasurable i a pro w uia n ts in 
quality of care; reductions in oosts of servio»; prooees for seeking 
redrass for injury frcn aialpractiod. or other unprofessional cxnduct, anii 
reduction in the potential ftor public harm fircn unregulated practioe. 

B* Cost ef fectivenass and eooncndo lurart can be evaluated 
through consideration of the following factars: 

(1) degree to %diich regulation directly or indirectly 
iiqpacts the oosts and prices of goodF or sendees provided by applicant 

(2) ispact ijpon the currant and future si^ly of 
practlticnerB of the regulated oou^tion; 

(3) degree to vhich existing practiticners will be precluded 
frtan practice because of regulation; 

(4) iapact, if anyr on innovations in delivery of care or 
services as a result of regulation; 

(5) oosts of additional education and training required as ^ 
result of regulatinn of the cocipation; 

(6) manner ii. lAiich and degree to irihich reguleition i»lll 
result in iap rc v anait in the quality of oare; 

(7) degree to which sezvioas of the applicant group 
substitute for cui^ently regulated occiqpations and estimted coqparative 
cost of applicant groip and currently regulated practitioners; 

(8) degree to which serHjoas of the applicant group 
supplement currently regulated occupa t i on s; 

(9) whether regulation confers or facilitate access to 
CTl"f ^^VHi iiMint for governunt assistance prograss such as medloare and 
aadicaid; estimated impact on piujiams and budgets; end 

(10) impact on expenditures by govermant and private third 
party payors, if any, resulting fkom regulation of the oooqpatj^* 

i^ppendlx vn 

HKnc wRL o atnssi ow pg r HEr uH caaa ' jj ' m) msbkjes' 


A oextlfying agency resqpcnBihle for attesting to the OGn{)etency of 
health care pmctitlcnerm has a reqpon e ibiJlty to the indivii^ials desiring 
oertlfioation, to the nplcyeirB of those im ividuals, to those agencies 
that reijdaiune fbr ttm servioes, and to the public. The itaticnal 
OGmnision for Heedth Outlfying Agandes y&B ftaned to identify hm those 
varying leepcnsihility can be met ani to C termine if a ^wtifying agenc^^ 
Mats thQ>e leqpGnsiblitifis. Nnbenhip of a oertifying agency in the 
Qoniiiission ixr^j^^ttee that the certifying agen^ has been svaluated the 
OoBmissicn am rtenml to neet all of the establiited criteria. In order 
to be **aiproyed** for mwixntdp in the Cuoission^ a certifying agency^ 
shall Bset the fblloving uritffila: 

1. Rsposa of Oertifying Agency 

a. 8ha3'i ywe as a prinary purpose vhe evalviaticn of those 

individuals «ho wish to enter, ocntinie ancVor advance in thr. 
health professions, throu^ the oertificatiGn process, and thb 
issuance of credentials to those individuals vho meet the 
reqpiired lervel of ccnpetenoe. 

2. Structure 

a. shall be non-goveniDental; 

b. shall conduct oertificaticn activities lAiich are national in 

c. tfiall be administratively independent in natters pu±aining 
to certification, eKcapt appointaQi^ of inenbers of the 
governing body of the oertifyiiij ageixqf. A certifying agency 
\t^:h is not a legal entity in and of itself shall provide 
proof that the agency ^s ga^^ijjjg body is administratively 
independent in certification natters froL the organization of 

it is a part; 

d. ir^iall iMB a governing body %jhicii indudep *ndividuals ttxn 
the ftifloipline being certified. certify^ j agency 
certifies noro than one disc^line cr rare than one level 
vittiin a discipline ihall have reprasent^^ion o£ each on tha 
governing body; 

^Ohe tern **oertifvlng agency** as ueid ii. this dc ow fli t neans an 
independent not* . "-profit oer.tifying agency or a not-for^frofit 
ssMciation vi^ a certifying uumxjwil . 

^Administratively inlependent neans that all policy decisions relating 
to certification natters are the sole decision of the certifying body and 
not siMbject to approval fay any other body, and tliat all financial natters 
O related to ttm opoonttion of the oertifying un ^ ien L are segregated trm 

ERIC tiXM of the professional aesodttion. q^.^ 

ihall x«qidri that wm±mem of tte gctvemlng bod/ «ho nprnetatt 
the oartif i«d pzofesslcn ihall te aelactad ty the certified 
pcofesaion cr hy an aaaociaticn of the certified profetticn 
and such aelaction iftiall not be subject to tppcwal by any 
other ixxlivldual cr ocganisation; 

f . iftiall hava fbtul pcooKiuraB far the aelecticn of BadMrs of 
the 79v«ming body which diall prohibit the 9oveming body 
Crcn selecting its successors; 

9* ahall pcovide svddenoe that the public ccsraRaner and the 
Kqpervlsinj professional anH/ae «iploy«rs of the health 
professionals havs irput into the pQlicias aid decisiora of 
the agency, sithar tloouc^ Msisership on the govriming body or 
thLoug^ fooxalized procedures as advisoes to the govnning 
body, ihls critsrion is sffectlve January 1, 1981; and 

u. the certifying body of a professional organization diall be 
separate fkos the aoczediting body of the professional 

3. Rasouxxses of Oertifying Agencies 

a. shaU provide evidence that the agency has the financial 
resouroes to properly conduct the certification activities; 

b. shall provdde evridenoe that the staff posse^ «s the knovledge 
and skill naoessary to conduct the oertifica:-lon program or 
has availabls and makes use of non-staff conetultants and 
professionals to sufficiently sqpplemant staff knowledge an! 

4. Evaluation Mechaniflo 

a. shall provide svidencse that the machanim used to eva'. jate 
individual ccnpetenoe is riajective, fair and based or the 
knowledge and skills needed to function in the health 

b. ihall have a fonoal policy of periodic ravistf of evaiuater. 
nedianians and ahaU provide evidence that the pcaicy is 
iofilcnanted to insure lelevitnoe of the BBchanisn to knovledae 
and skills needed in the pcofession; 

c. ihall provicTe? cvidenoe that appiroparlate aaasures are takm to 
protect the security of all eoaminationa; 

d. ^hall provide svldircR that paas/fhi] levels az« sstabliBhed 
^ ^ "anner that is, generally acnqpted in the psychonetrlc 
ccnrunity as being ftJr and rea^mable. This criteria is 
effective January l, 1981, ifter standards are established; 


itell provide mridehot that the evalxiaticn ude ervddenoe at 
attflipts to establish both xeliability and validity for wch 
fom oC the mamijiation. 

5. Mblic Xhfdnnatia 

a. ihall publidi a doounent \tdx±i clearly definee the 

ceritif icaticn raqpcneibilities of the agon^ and outlines any 
other activities of the agency %ftiich are not related to 

b. itell aate available generai d es c ri ptive naterials en the 
prccedures used in test OGnstxucticn and validation and the 
prooadoras of adodnistration and reporting of results; 

c. AaJl puUliflh a ccnpntensive sonary or outline of the 
infoaxttticn, knowledge, or functions co v ered by the test; and 

d. ihall publish at least annually, a siosnary of certification 
activities, including nnter tested, nariber passing, nuniser 
failirig, nunfcer certified and nnter recertified (If agency 
conducts a recertif iceticn progrBm) • 

6. Raqponsibili^ en Applicants lac OBrtificaticn or ReoertificatiGn 

a« riiall not discriminate among applicants as to age, sex, race, 
religion, national origin, handicap or marital status and 
riiall include a statement of non-discrimLiatlon in 
amounooDBnt al the certification program; 

b. shall provide all applicants wi^ copies of fonmllzed 
procedures for appHcaticn for, and attainnent of, 
certification and ah&ll provide evidence to the Cmvnission 
that sudi procedures are tmifonaly follcwed and enforced for 

c. tfiall have a formal policy for the periodic review of 
iqpplloatlon and testing procedures to Insure that t^3y are 
fair and equitable and ^lall give evidence to the Camdssion 
of the iiqplementaticn of the policy; 



d. ihall puh\irdze nationally oppcqpriate data oonoemixig 
oartifi&ati'n progr a m including eligibility raqpdxcaients for 
oertif.^joatien, basis of axBsdnatien, datas and places of 

e. ihalA pravldB cvidenoe that oaqpetoitly prcx±arad testing 
sites are raadily aooassible in all areas of the nation at 
least onoe annually; 

f . shall r »*>li c i ae nationally ttm tpecitic education becSagrcund 
or aplayoent badogcund reqtiired fbr osrtification; 

g. itell given evi&nce that a Beans exists for inliviAials %t)o 
have cbtained a skill or knowledge outside the f ocnal 
educbtional setting to be eval^«ted and obtain certification 
or in the tbeenoe of such anans, provide reasonable 
justifica t ion for SMClusion. Ohase uaans oqployed should be 
consistent with the ev«aluation standards. Ihe oriterion is 
effective January 1, 1982; 

h. shall prcvide evidenon of unifonnly pr o fit reporting of test 
results to applicants; 

i. ihall provide evidence that applicants failing the examination 
are given infomation on gen^nl areas of deficimq^; 

j. shall provide evidence that each applicant's test results are 
held confidential; 

k. stall have a foznal policy on aipeal procedures for ^splicants 
Questioning examination results and shall publif h this 
infarnation in examination anncuncenents; and 

i. shall have a formal policy, f>aoeptable to the Oamdssion, 
delineating grounds, bsmd on applicants prior or currant 
conduct, for refusing ^licants eligibility to take the 
certi f icatio n examination and shall provide applicants the 
opportunity to present their oases to an iipertial 
decisionn^oar in the event of djiied of eligibility cr doiial 
certification. (Effective January 1, 1987) 

Rasponsibrnties to the Fiftaic and to Ikployers of 
certified Fersamel 

a. ihPll drive to insure that the examination adequately naasureo 
the knowledge and skill requirBd for entry, acdntenanoe anVor 
advanoentent into the profession; 

b. tfiall poxvida evldam that the agency aMords certification 
only tifter the tfdll and knowledge of the Individual has been 
evaluated and determined to be acceptable; 

c. tfiaU periodically publish a list of tlioae parsora certified 
by the agscy; 

d. ihaU hHV» a fannal wdicy and procjecJure for discipline of 
oartifioantf?, including tha aancticn of rBvooaticn of the 
oertlficata, far ooreJuct %*xieh claarly indicatas Inocopetenoe, 
unethical .bfltevicr and physical or aental lsi>ainnent affecting 
perfonanoft that is acceptable to the Oomnissicn, Oheae 
pcocadores «»all ixxxcpocata due prooMS. (Effective Jaruary 
1, 1987); 

a. any title or cradential awarded by the cxedentialing body 
ihall cwrepriately reflect the practiticner daily oco^tonal 
dotias and ohall not be oonfusing to mfD-t^rere, oonsuners, 
health ptofassionala amVor other interested parties effective 
Janiary 1, 1985); 

rjie na±ierhship Oomnitbae nay consider the follcwing factors 
in etemlniJ^ whether practitioner's tiUes or credentials 
axply with this criterion: 

(i) educational background; 

(ii) function of profession; 

(iii) occtqpational duties and breadth of 

these activities; 

(iv) level of supervision by iTther 

practitioners, or of any other 
practitioners; and 

(V) various tiUes already in the field, 

other titles considered, and a 
justification of why thss»* tiUes were 
not utilized or vtiy they were changed. 

8. Recertificaticn'^ 

a. shall have in ecdstenrse or shall be in the process of 
developing a plan for periodic reoertification: 

b. shall provide evidence that any recertification program is 
designed to neasure '^'ontimed ocnpetcnoe cr to enhance the 
continued ccqpeteroe of the individual. 

9. F^qponsibilitifls to Oonnission 

a. tfiall provide the Qsmission on a regular basis with copies of 
all pddlicati^ related to the certifying prooess; 

b. shall advise the Oonnission of any change in puiFOse, 
structure or activities of the ontifying agency; 

this )<ooiBBnt the term "reoertification" includes periodic raneual 
cr rwalidatin of certification based on re e ufwml n ation, oontiming 
education or other nethodto developed by the certifying agency. Ihis 
criterion is effective January 1, 1982. 



c. ihall adviM ttw Oomnificdon of stdbstantive change in test 
aaninistxaticn pcooadures; 

^' Oo™>iMlon of any aajor chanoes in testing 

tachnli3Ma« or in the aoope or dbjectijee of tS^cest?^^ 


Amended Deccnber, 1984. 

In this docunent the tern "raoertif Icatlcn* includes periodic zmewal or 
SSi?^"' ^y^^iS^ ^ « ».«amlnaUon,^SSSlJ^ 

5^ SSSLf^ developed by the oertilyinj agen^Tniis 
criterion is effective Januazy l, 1982. * -sr- jr 

J^ppendix Vin 

American Diatetic Association (1972) Protesaian of Dlcteticst Reoort. 
of the Study Qamd^icn en Digtetles. Qiicago: la^rican Dietetic 

Jtaerican Dietetic Association (1985) A Mew look at t!^ Prof^lon Of 
Dietetics n fm-*" »^ 1984 study Qmmigsicn en Dietetics. Qiicagp: 
American Dietetic Association. 

American Hedical Association (1987) ftlUffl ft**"*^^ TW.v^»<nn nirer^^ - 
1987 . Chicagp: American Hedical Associatia.. 

American Riysical Dierapy Association (ca. 1980) A ^iaim tOC OwWRr 
Alexandria, VA: Ihe Association, imdated. 

American Society of ainical PathologiBts (1987) Board of Registry 
Mewsletter. Kaxch. 

American Society for Hedical Technology, (CA. 1981 ) "Mission Statement," 
undated %«all plaque. 

"Die Beginnings of 'HcxSexn Riysiotherapy'" in ITw E?Tinnim?T J^^^^ai 
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"AMRA: Hhe Fixet 20 Years." (1978) Ksdial-BBSBCOaSf August. 

Biglow, L.A. (1982) "Hedical Records Education: An Ifistorical 
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Burton, G.G., & Hcdgkin, J.E. (1984) Pespiratorv ttre 2nd ed. 
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Oorbett, F.R. (1909 "Ihe Itaining of Dietitians for Hospitals," Jwmal Qt 
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pietetics . 

Ooltey, R. W. (1978) ffuryfy gf Tteehnoloav. Chapter 1. St. Icuis 

H3; C.V. Noidby. 

"DMital H^glsne" (1845) editorial, fmeriean Journal of Dental Scimoe. 
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"Editorial: Dental Ilygiane", (1845) ^merlaan JgunWl Pf PBrt^"* fif^<««e 
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Tw, N. (1979) "Changing Radiologic Technology Education: Evolution or 
Itavoluticn? Pazt I" Hadloloaie Tachry>logy. ^(6). 

Piy, M. (1979) "Oianging Radiologic TKhnology Bducaticn: Evolutlcn or 
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Itortkidck, D.F., Marziflon, J.I., & cassid^, p.A. (1985) "fienpectives in 
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Hazertiyer, I.M. (1946) "A History of tte Jmarican Rxysiothen^ 
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Iici)ldns, H.L. (1983) "An Historical Perapecltive cri Ooovational Ihetapy,; 
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cited in Williams, R. M. An mtmauetlon to the P mfesslcn of vm^c^^ 
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